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BOOKS BY EMILY A. M. STONEY 



Practical Points in Nursing 
i2mo of 511 pages, illustrated. Revised by 
LUCY CORNELIA CATLIN, R. N. Cloth, 
$1.75 net. Fi f th Edition 



Materia Medica for Nurses 
i2mo of 306 pages. Cloth, $1.50 net. 

Third Edition 



Bacteriology and Surgical Technic for Nurses 
i2mo of 342 pages, illustrated. Cloth. 



Fourth Edition 



BACTERIOLOGY AND 

SURGICAL TECHNIC 

FOR NURSES 



BY 

EMILY A. M. STONEY 

Formerly Superintendent of the Training School for Nurses, Carney 

Hospital, South Boston, Mass.; Author of "Practical Points in 

Nursing," " Practical Materia Medica for Nurses" 



FOURTH EDITION 
ENLARGED AND RESET 



"Every bit of knowledge that we cannot use for the uplifting of our phys- 
ical, intellectual, or emotional life is so much waste of lime and labor. 
Everything taught is worth the knowing, but not worth the putting away 
in the pigeon-holes of memory to be recalled some day by accident 1 ' 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1916 



-tffl 



99 



Copyright, 1900, by W. B. Saunders and Company. Set up. electrotyped, printed, and 
copyrighted September, 1900. Reprinted September, 1902. Revised, reprinted, and 
recopyrighted January, 1905. Reprinted March, 1906, November, 1907, Feb- 
ruary, 1909, and August, 1909. Revised, reprinted, and recopyrighted Sep- 
tember, 1910. Reprinted July, 1912, and January, 1914. Reprinted 
September, 1915, and December, 1915. Revised, entirely reset, 
reprinted, and recopyrighted September, 1916 



Copyright, 1916, by W. B. Saunders Company 



7 



r 



BGT-5 1916 



PRINTED IN AMERICA 



PRESS OF 
B. SAUNDERS COMPANY 
PHILADELPHIA 



'cu-i;*-: 



TO 



DR. JOHN R. SLATTERY 

THIS VOLUME IS DEDICATED BY THE AUTHOR 

IN GRATEFUL REMEMBRANCE OF MUCH ENCOURAGE- 
MENT AND PERSONAL KINDNESS 



PREFACE TO THE FOURTH EDITION 



To bring this new edition down to date the text and 
illustrations have been gone over in a thorough manner. 

While the general plan of the book remains the same, 
the addition of new matter and the elimination of obso- 
lete material have necessitated the entire resetting of the 
work. 

The chapters requiring the most revision were those 
on Antiseptics, Disinfectants, and Deodorants; Gauze 
Sponges, etc.; Minor Surgical Procedures, and Sequels 
of Operation. So extensive were the changes in the 
chapters on Bandages and Dressings, Instruments, and 
Anesthesia that they had to be entirely rewritten. 
Some of the more important additions are the follow- 
ing: Antityphoid Vaccine; Antitoxin in Cerebrospinal 
Meningitis; Flexner's Serum in Infantile Paralysis; 
Serum Reactions; Method of Passing Stomach-tube; 
Murphy's Method of Continuous Proctoclysis. 

It is hoped that the present edition will serve as useful 
a purpose as its predecessor. 

September, 19 16. 



PREFACE 



The following pages constitute the notes of a series 
of lectures on "Bacteriology and Surgical Tech- 
nic" which followed closely upon my lectures on 
" Materia Medica." The first part of the book is de- 
voted to Bacteriology and Antiseptics ; the second 
part to Surgical Technic, Signs of Death, Au- 
topsies. 

No attempt has been made to write a complete 
treatise on bacteriology, but merely to outline and 
simplify that branch for nurses. 

It was deemed advisable to add the chapter on 
"Signs of Death and Autopsies," as many nurses 
are unacquainted with the preparations for an autopsy 
in private practice. 

So many changes have taken place in surgery since 
the lectures were delivered that it has been necessary 
to rewrite many of the chapters. In this I was 
assisted by Dr. A. S. Allen and by Professors J. B. 
Murphy, Christian Fenger, and Joseph L. Miller, of 
the Northwestern University Medical College. I am 
glad of this opportunity to thank them for their 
assistance. 

11 



12 PREFACE 

Free use has been made of the works on bac- 
teriology by McFarland, Crookshank, and Woodhead; 
of "Aseptic Surgical Technique," by Dr. Hunter 
Robb ; "Operative Gynecology," by Dr. Howard A. 
Kelly; and "Aseptic Treatment of Wounds," by 
Dr. C. Schimmelbusch. 

I am unable to express my indebtedness to Dr. 
Joseph P. Comegys for his valuable assistance with 
the manuscript and its preparation for the press. 

I wish also to thank Drs. George L. Eyster and 
Charles C. Carter for their friendly help and interest 
in the work. 

EMILY A. M. STONEY. 



CONTENTS 

PART L-BACTERIOLOGY; ANTISEPTICS 



CHAPTER I page 

History of Bacteriology » - *7 

CHAPTER II 

Bacteria as the Causes of Disease 28 

CHAPTER III 
The Theory of Antitoxins 45 

CHAPTER IV 
Antiseptics, Disinfectants, and Deodorants 53, 



PART IL— SURGICAL TECHNIC 



CHAPTER V 

Bandaging and Dressings 65 

CHAPTER VI 

Care of Operating-room; Methods of Sterilization; Care 
of Instruments 102 

13 



14 CONTENTS 

CHAPTER VII 

PAGE 

Instruments Necessary in Different Operations, Keeping 
of Charts, Surgeon's Kit, etc ; 116 

CHAPTER VIII 
Anesthesia 144 

CHAPTER IX 

Gauze Sponges; Pads; Dressings; Tampons; Dressing-room 
Outfit; Drainage, Care of Drainage-tubes; Gloves; 
Sutures and Ligatures; Surgical Applications 178 

CHAPTER X 
Inflammation 197 

CHAPTER XI 

Catheterization; Douches; Enemata; Washing out the 

Bladder; Lavage 20c 

CHAPTER XII 
Minor Surgical Procedures 215 

CHAPTER XIII 
Obstetrtc Nursing; Care of Infants, etc 233 

CHAPTER XIV 

Operation's; Preparation of the Operating room; the Sur- 
geon and His Assistants , 239 

CHAPTER XV 

Transportation; Preparation of Patient for Operation; 
Care of Patient During and After Operation 249 

CHAPTER XVI 

Sequels of Operations; Shock, Hemorrhage, Septic Peri- 
TONiTis, Accidents During Operation, etc 263 



CONTENTS 15 

CHAPTER XVII p AGE 

Special Opeeations 276 

CHAPTER XVIII 

Operations in Private Practice 278 

CHAPTER XIX 

Gynecologic Examinations and Operations 288 

CHAPTER XX 

Diet Recipes 299 

CHAPTER XXI 

Signs of Death; Autopsies 306 

CHAPTER XXII 

Hygiene; Personal Conduct of a Nurse's Life; of the Re- 
wards; Success 311 

Glossary 317 

Index 329 



PART I 
BACTERIOLOGY; ANTISEPTICS 



CHAPTER I 

HISTORY OF BACTERIOLOGY 

The eye is one of the most beautiful and delicately 
contrived organs in the body, and yet its vision un- 
aided is very limited in its scope. We see so much that 
we rarely stop to think of what an enormous world 
exists in and all about us which we cannot see at all — 
a world peopled by organisms so very small that they 
can be seen and studied only by the aid of the most 
powerful magnifying lenses, and so numerous that they 
are quite beyond any calculation. 

Bacteria exist nearly everywhere; they are almost 
universal, except that they are not found deep down 
in the ground nor high up in the air. They and their 
spores, or seeds, float in the air we breathe, swim in the 
water we drink, grow upon the food we eat, and lux- 
uriate in the soil beneath our feet. Wherever man, 
animals, and plants live, die, and decompose, bacteria 
are sure to be present. They are always on the surface 
of the body, and so deeply are some bacteria situated 
beneath the epithelial cells that the most vigorous scrub- 
2 17 



1 8 BACTERIOLOGY 

bing and washing and the use of powerful disinfectants 
are necessary to remove them from the surgeon's hands. 

The mouth is said to be always replete with them; 
and, since many are swallowed, the digestive tract 
always contains them. The germ of pneumonia, for 
instance, is said to be habitually present in the mouth 
of almost every healthy person; consequently, its en- 
trance into the lungs is only a matter of accident. 

The existence of these bacteria has been known for 
many years, but it is only during the past few decades 
that any great advancement in our knowledge of them 
has been made. 

Over two hundred years ago a man named Athana- 
sius Kircher, a German, mistook blood-corpuscles 
and pus-corpuscles (leukocytes) for small worms, and 
built up a new theory of the causes of disease and 
putrefaction upon this basis. At the same time 
Christian Lange, a professor in the medical school at 
Leipzig, expressed his opinion that the rash that ap- 
peared on the skin in the eruptive fevers, etc., was 
the result of putrefaction conveyed by small living 
worms in the body. Shortly after these observa- 
tions came those of Anthony van Leeuwenhoek, a 
native of Delft, in Holland, who, in his early years, 
had learned the art of polishing lenses, and who was 
able, ultimately, to produce the first really good micro- 
scope that had yet been constructed. He saw, and 
described with astonishing clearness, various forms 
of bacteria found in the material taken from the mouth 
of an old man who never cleaned his teeth. He gave an 
accurate description of the rod-shaped bacteria, motile 
and motionless, now called bacilli ; of the spiral threads, 



HISTORY OF BACTERIOLOGY 1 9 

or spirilla; and of rounded micro-organisms, or micro- 
cocci. Although he did not attempt to theorize as to 
the meaning of these organisms at the time, later on, in 
1 713, after finding similar organisms in the greenish 
pellicle formed on the surface of the water in an aquarium, 
he came to the conclusion that the various forms of 
bacteria found in the material scraped from the teeth 
found their way into the mouth through the medium 
of the drinking-water that had been stored in barrels, 
and that some of these found there a nidus in which 
they multiplied. 

This was the real beginning of bacteriology; and 
from this origin the study advanced with considerable 
rapidity in spite of ridicule and much opposition, 
Various opinions regarding the connection of these 
germs with disease and putrefaction were put for- 
ward, but it was not until 1831 that any important 
advance was made in our knowledge of this connec- 
tion. Previous to that time a large mass of facts in 
regard to these little living organisms was being gradu- 
ally accumulated, and fresh discoveries were constantly 
made by various workers; but since no systematic at- 
tempts to classify the newly observed facts were made, 
the scientific results were very small. 

The first real advance made in our knowledge of 
the presence of a living contagious element in the 
production of disease and fermentations was made 
by Frederick M uller, of Copenhagen, and was the 
result of a systematic attempt to arrange the knowl- 
edge which had been accumulated during all those 
years. From that time to the present the science 
has made great strides; so that we have now an accu- 



20 BACTERIOLOGY 

rate knowledge of the bacteria which cause a number of 
different diseases. The knowledge of methods and 
details of work is now so general that the science of bac- 
teriology is rapidly growing, and has already revolution- 
ized very many branches of medicine. 

In 1840 Henle was led to believe that the cause of 
miasmatic, infective, and contagious diseases must be 
looked for in living fungi or other minute living or- 
ganisms. Unfortunately, at that time the methods 
of study employed prevented him from demonstrating 
the accuracy of his belief. It was left for Pasteur and 
Koch to complete the work. Davaine, in 1848, was 
the first to see and to recognize disease-producing 
bacteria — he saw anthrax bacilli in the blood of sheep 
dead of splenic fever. 

Pasteur then took up the work;- and in 1857 his 
faultless demonstration of the germ theory of disease 
was brought out as a result of his experiments on fer- 
mentation and putrefaction, and on the bacteria of 
wine and those of the silkworm. He showed that the 
acetic fermentation, viscosity, bitterness, and turning 
flat of wines are due to the action of certain organized 
ferments, and demonstrated a causal relation between 
certain lowly organized parasitic organisms and spe- 
cial diseases *in animals and insects. Upon Pasteur's 
observations Lord Lister based his successful system 
of the treatment of wounds, known as " antiseptic sur- 
gery." 

We all know of the wonderful success which now 
marks the operations of major surgery, and of the 
daring boldness of operators who attempt what was 
utterly impossible as long as antiseptic surgery was 



HISTORY OF BACTERIOLOGY 21 

unknown. Lister, accepting the truth of Pasteur's 
statement — that germs are the producers of fermenta- 
tions — concluded that germs entering wounds from the 
outside might be the cause of suppuration; and since 
germs are always and everywhere floating in the air, 
suspended in water, and attached to the surgical in- 
struments, dressings, and sponges used in operations, 
he judged correctly that it was highly advantageous 
to employ an antiseptic agent in order to kill any of the 
suspended or adherent organisms before any materials 
could be allowed to come in contact with wounded 
tissues; consequently, the hands of the operator and 
his assistants, the surgical instruments, sponges, dress- 
ings, sutures and ligatures were kept constantly satu- 
rated with a solution of carbolic acid (i 140), and the 
operation was performed under a spray of carbolic acid 
(1 :2o). Carbolized dressings were used; and if the 
discharge was profuse, the dressings were changed 
once in twenty-four hours under a constant use of the 
spray. The researches of a later date have shown, how- 
ever, not only that the atmosphere cannot be disin- 
fected, but also that the air of ordinarily quiet rooms, 
while containing the spores of numerous saprophytic 
organisms, rarely contains many pathogenic bacteria. 
We also know that a direct stream of air, such as is 
generated by an atomizer, causes more bacteria to be 
conveyed into a wound than ordinarily would fall 
upon it, thereby increasing instead of lessening the 
danger of infection. Lister, we must remember, was 
not the discoverer of carbolic acid nor of the fact that 
it would kill bacteria; but, convinced that inflamma- 
tion and suppuration were caused by the entrance of 



22 BACTERIOLOGY 

germs from the air, instruments, sponges, and dress- 
ings into wounds, he suggested the antisepsis which 
would result from the use of sterile instruments, clean 
hands, dressings, towels, and the like; and made ap- 
plications intended to keep the surface of the wound 
moistened with a germicidal solution in order to kill 
such germs as might accidentally enter. He also 
introduced the practice of concluding operations by 
the application of a protective dressing, such as would 
tend to preclude the entrance of germs at a subse- 
quent period. This procedure defeats its purpose 
for usefulness by reason of the moisture retained acting 
as a direct growth medium for those bacteria already 
upon or in the skin. Listerism has spread slowly but 
surely to all the departments of surgery and obstetrics. 

Since Lister's treatment was first inaugurated, many 
details of its application have been variously modified 
and great additions to our knowledge have been made. 
In bacteriology much important work has been done, and 
great advances are being constantly made. There are a 
number of diseases, each one of which has been definitely 
proved to be caused by a germ of its own, a germ which 
causes no other disease. There is also a list of diseases 
in which the proof is not yet conclusive, but for which 
the probability is that a specific germ will be found. 
The following data have been gathered chiefly from the 
works of McFarland and Woodhead: 

In 1845 Langenbeck discovered that the specific 
disease of cattle known as actinomycosis could be com- 
municated to man. His observations, however, were 
not given to the world until 1878, one year after Bollinger 
had discovered the cause of the disease in animals. 



HISTORY OF BACTERIOLOGY 23 

In 1847 Semmelweis, on the basis of his own ob- 
servations, formulated the precept that puerperal fever 
is the result of the introduction of organic ferments into 
the puerperal genital tract. This discovery, established 
by himself and confirmed by the observations of many 
others, marked an era in obstetrics. The organic fer- 
ments have since been identified as specific bacteria. 
Semmelweis in this way anticipated in practical anti- 
sepsis the discoveries of Lister and Pasteur; while the 
late Oliver Wendell Holmes, in a paper entitled "Puer- 
peral Fever a Private Pestilence," published in 1843 and 
republished in 1855, in treating of its prophylaxis, an- 
ticipated the teaching of Semmelweis. Semmelweis 
was first led to recognize the source of puerperal in- 
fection by the case of Prof. Koletschka, of the Univer- 
sity of Vienna, who, having received a dissection wound, 
became thereby fatally infected. In consequence of this 
Semmelweis concluded that there was an identity between 
this infection and that of which so many hundreds of 
puerperal women died. In the school for instruction 
in practical obstetrics with which he was connected 
there were two departments, one for medical students, 
the other for midwives, the students going, as a rule, 
directly to the obstetric ward from the autopsy room. 
He first noted the much greater mortality in the stu- 
dent's ward, and in May, 1847, began to require the 
students to wash their hands in chlorin-water before 
making vaginal examinations, thereby reducing the 
puerperal mortality to a point lower than had been 
ever before reached. 

In 1863 Davaine established by experiments the bac- 
terial nature of splenic fever, or anthrax. 



2\ BACTERIOLOGY 

In 1869 the first complete study of a contagious 
affection was made by Pasteur, in two diseases affect- 
ing silkworms — pebrine and flacherie — which he showed 
to be due to micro-organisms. 

In 1875 Koch described more fully the anthrax 
bacillus, gave a description of its spores and the prop- 
erties of the same, and was enabled to cultivate the 
germ on artificial media; and, to complete the chain of 
evidence, Pasteur and his pupils supplied the last link 
by reproducing the same disease in animals by artificial 
inoculation from pure cultures. The study of the bac- 
terial nature of anthrax has been the basis of our knowl- 
edge of all contagious maladies; and most advances in 
technic have been made first through the study of the 
bacillus of that disease. 

In 1879 Hansen announced the discovery of bacilli 
in the cells of leprous nodules. They were subse- 
quently clearly described by Xeisser. From the nature 
of the symptoms and from the course of the disease, 
leprosy up to this time was long considered to be a 
disease similar to tuberculosis, and the discovery of the 
bacillus paved the way for the reception of Koch's 
discovery of the tubercle bacillus. 

In the same year Xeisser discovered the gonococcus 
to be the specific cause of gonorrhea. 

In 1880 the bacillus of typhoid fever was first observed 
by Eberth, and independently by Koch. 

In 1880 Pasteur published his work upon Chicken- 
cholera, an epidemic disease which affects turkeys, 
pigeons, chickens, ducks, and geese, and which causes al- 
most as much destruction among them as the occasional 
epidemics of cholera and small-pox produce among men. 



HISTORY OF BACTERIOLOGY 25 

In the same year Sternberg described the pneumo- 
coccus, calling it "Micrococcus Pasteuri," which he 
secured from his own saliva; and in the same year 
Pasteur also found the same organism in saliva; though 
it is to Frankel, Talamon, and particularly Weichsel- 
baum that we are indebted for the discovery of the 
relation which the organism bears to pneumonia. 

In 1882 Robert Koch made himself immortal by 
the discovery of and work upon the bacillus of tuber- 
culosis, one of the most dreadful and, unfortunately, 
most common diseases of mankind. While great 
men of the earlier days of pathology clearly saw that 
the time must come when the parasitic nature of this 
disease would be proved, and some, as Klebs, Ville- 
min, and Cohnheim, were "within an ace" of the dis- 
covery, it remained for Koch to succeed in demonstrating 
and isolating the specific bacillus, and to write so accu- 
rate a description of the organism and the lesions it 
produces as to render the discovery one of the most 
complete ever made in the history of medical science. 

In the same year LorBer and Schiitz reported the 
discovery of the bacillus of glanders, an infectious 
disease almost confined to certain of the lower ani- 
mals; although occasionally persons whose habitual 
association with and experimentation upon animals 
bring them into frequent contact with such as are 
diseased, have become accidentally infected. 

In 1884 Koch discovered the "comma-bacillus," the 
cause of cholera. 

In the same year Loffier discovered the diphtheria 
bacillus, and Nicolaier that of tetanus. 

On October 26, 1885, Pasteur made the first applica- 



26 BACTERIOLOGY 

tion of his method for the treatment of hydrophobia, 
nearly ten years before the time we began to understand 
the production and use of antitoxins in human medicine. 

In 1890 Koch issued to medical men what is known as 
tuberculin, a brownish, syrup-like fluid used in the 
diagnosis and treatment of tuberculosis. 

In 1892 Canon and Pfeiffer discovered the bacillus 
of influenza. 

In 1894 Yersin and Kitasato independently isolated 
the bacillus causing the bubonic plague then prevalent 
at Hong-Kong. 

The bacterial cause of yellow fever has not been deter- 
mined, but its method of transmission is known to be 
through the bite of the mosquito Stegomyia fasciata. 
This mosquito, to become infected, must bite the patient 
during the first three days of the disease, and then the 
mosquito is harmless until the lapse of at least twelve 
days. After being bitten by the mosquito the period 
of incubation is from six to ten days. Dr. Chas. Finlay, 
of Havana, was the first to pronounce clearly a mosquito 
theory of the transmission of yellow fever, and it was 
later proved conclusively by a Commission of the 
United States Army composed of Reed, Carroll, Agra- 
monte, and Lazear. Two of the above, Reed and 
Lazear, died from allowing themselves to be bitten by 
infected mosquitoes to prove conclusively that the 
mosquito, and the mosquito alone, transmitted the 
disease. 

Epidemic cerebrospinal meningitis or spotted fever is 
caused by Diplococcus intracellularis meningitidis. 

Malta fever, a disease of the Mediterranean islands, 
and occasionally of the Antilles and Central and South 



HISTORY OF BACTERIOLOGY 27 

America, is due to a micrococcus discovered by Bruce, 
and called Bacillus melitensis. 

Malarial fever is an infectious disease; but, unlike 
those mentioned, it is not caused by a vegetable germ, 
a bacterium, but by a microscopic animal, the Plasmo- 
dium malarice, which is found in the blood of the afflicted 
individual. Malaria is carried solely by a species of 
mosquito, the Anopheles. 

There is some grounds for a belief that malignant 
tumors — cancers and sarcomas — are due to micro- 
organisms. The nature of the parasite is as yet un- 
known. 

Spirochaeta pallida or Treponema pallidum, discov- 
ered by Schaudinn and Hoffmann in 1905, is now 
generally accepted as the exciting cause of syphilis. 
The organism is from 6 to 15 /W in length and presents from 
six to fourteen spiral turns. It is found constantly in 
primary and secondary and with difficulty in tertiary 
lesions. Its presence in a suspected lesion is regarded as 
diagnostic, while its absence does not exclude syphilis. 



CHAPTER II 

BACTERIA AS THE (CAUSES OF DISEASE 

Diseases may be divided into two great classes — 
the constitutional, which are due to such causes as 
errors in diet, alcoholic excesses, overwork, or age; 
and the infectious or contagious, which are due to the 
introduction into the body of a living poison. We no 
longer look upon infectious and contagious diseases 
as due to an unexplainable something, whose source 
we cannot know, whose course we cannot predict, and 
whose end cannot be hastened by any efforts on our 
part. Investigation has shown that we are no longer 
fighting an unknown enemy in the dark, but that we 
have before us a definite, living thing, whose part in 
the plan of creation is as surely fixed as our own, whose 
life-history can be told, and whose growth is as de- 
pendent on the right amount of light, food, heat, and 
air as that of the rose in our garden. 

The word bacteria is a general name for all the plant 
micro-organisms. Of these there are many different 
classes with different names. They vary much in shape 
and size, some being round, some thread-like, some rod 
shaped, and some of a spiral form. Each single organ- 
ism consists of a small speck of protoplasm or vegetable 
albumin, to which may be given the name of a cell; and 
these cells are so minute that they can be seen only with 
the aid of the best microscopes at our command. The 
28 



BACTERIA AS THE CAUSES OF DISEASE 29 

rounded organisms, or micrococci, as they are called, 
are seldom more than Towc inch in diameter; the 
elongated cells average a little more perhaps, and are 
from T2W0 to 6W0 m ch in length. Different forms natu- 
rally vary from this standard of size; but these figures 
will give a good idea as to the actual size of the forms 
under consideration (Fig. 1). 

The fungi connected with disease in man are divided 
into three classes: 

1. Molds, or hyphomycetes. 

2. Yeasts, or blastomycetes. 

3. Bacteria, or schizomycetes. 



flfy 



^ f & 



Fig. 1. — Various forms of bacteria: 1 and 2, Round and oval micro- 
cocci; 3, diplococci; 4, tetracocci, or tetrads; 5, streptococci; 6, bacilli; 7, 
bacilli in chains, the lower showing spore formation; 8, bacilli showing 
spores, forming drumsticks and Clostridia; 9 and 10, spirilla; 11, spiro- 
chetal (McFarland) . 

Some bacteria, or schizomycetes, induce the various 
fermentations; while others are productive of putre- 
faction, and are called saprophytes. Others, again, 
known as the pathogenic bacteria, are the cause of 
various diseases; while those which do not ordinarily 
cause disease are known as the non-pathogenic bac- 
teria. The chief forms of bacteria are: 

1. The coccus — berry-shaped or spheric bacterium. 

2. The bacillus — rod-shaped bacterium. 

3. The spirillum — corkscrew bacterium. 

And these, which are species relatively monomorphous 



3o 



BACTERIOLOGY 



— i. e., preserve their shape — are practically the only 
ones with which we have to do. 

The cocci are named according to their arrange- 
ment with one another; if, for instance, they are in 
pairs, they are called diplococci; if in a chain, they are 
called streptococci ; if in a cluster, like a bunch of grapes, 
they are called staphylococci; and if in an irregular 
mass, stuck together by a thick substance, they consti- 
tute a zooglea. Those developing in fours are called 
tetrads; in eights, sarcinse. 






99 99999 ^^Us? ®® ® 



© o 

® © 

g h i j 

Fig 2. — Diagram illustrating the morphology of cocci: a, Coccus or 
micrococcus; b, diplococcus; c, d, streptococci; e, f, tetragenococci or 
merismopedia; g, h, modes of division of cocci; i, sarcinae;^, coccus with 
flagella; k, staphylococci (McFarland). 

The cocci are also named according to their func- 
tions, as, for instance, "pyogenic," or pus-forming; the 
specific name also describing the form, arrangement, 
color, and function; for example, Staphylococcus pyogenes 
aureus signifies a spheric colorless micro-organism form- 
ing a yellow pigment, arranging itself with its fellows 
into the form of a bunch of grapes, and producing pus. 

As the surgical nurse carries on a daily warfare for 
the destruction of pus micro-organisms and prevention 



BACTERIA AS THE CAUSES OF DISEASE 3 1 

of their growth, she cannot be too familiar with every 
aspect of these germs. The two most constant pus 
formers are: (1) the staphylococcus (Fig. 2, k), which, 
when present in a wound, may cause a free flow of 
pus; still it generally manifests a milder disease con- 
dition than the virulent (2) streptococcus germ (see Fig. 
1, No. 5; Fig. 2, c, d). 

Staphylococci may be observed under the microscope 
by placing a drop of the pus upon a cover-glass, after- 
ward spreading the specimen by applying another 
cover-glass; dry over an alcohol lamp and stain with 
a solution of methylene-blue. Wash away the excess 
and place the specimen face down upon a glass slide. 
Streptococci are best stained by the so-called Gram 
method. To a dried and spread drop of pus upon a 
cover-glass apply an excess quantity of the following: 

Anilin, 4 parts. 

Saturated alcoholic solution of basic 

anilin dye, 11 " 

Water, 100 " 

Stain in this for fifteen minutes; transfer to Gram's 
solution : 

Iodin, 4 parts. 

Potassium iodid, 2 " 

Water, 300 " 

Stain for four minutes; remove and wash the specimen 
in 95 per cent, alcohol; finally stain in the following for 
half a minute: 

Bismarck brown, 3 parts. 

Water, 70 " 



32 BACTERIOLOGY 

Wash in 95 per cent, alcohol; clear the specimen by 
adding a few drops of carbolxylol; place upon a glass 
slide for observation. Anyone capable of developing 
an ordinary kodak film will find but little difficulty 
in learning this apparently deeply mysterious technic 
of the bacteriologic laboratory. 

Bacteria reproduce in two ways: By direct division 
(fission) and by the development of spores or seeds 
(sporulation) . The most common mode is by binary 
division, one body dividing itself so as to form two 
other bodies; these two re-dividing, and so on. It 
can readily be imagined how quickly an appalling in- 



CS> < g) O O o C£=> gz3 

a b c d e f 

Fig. 3. — Diagram illustrating sporulation: a, Bacillus inclosing a small 
oval spore; b, drumstick bacillus, with terminal spore; c, Clostridium, 
with central spore; d, free spores; e and /, bacilli escaping from spores 
(McFarland). 

crease in their numbers can be thus brought about; 
but, fortunately, this multiplication only takes place to 
advantage under certain favorable conditions; if these 
are not present the bacterium begins to degenerate, 
but usually does not die until it has left behind a spore. 
When the formation of a spore is about to commence, 
a small bright point appears in the protoplasm, and 
increases in size until its diameter is nearly or quite 
as great as that of the bacterium. As it nears perfec- 
tion a dark, highly refracting capsule is formed about 
it. As soon as the spore arrives at perfection the bac- 
terium seems to die, as if its vitality were exhausted 



BACTERIA AS THE CAUSES OF DISEASE 33 

in the development of the permanent form. As soon 
as the young bacillus escapes it begins to increase in 
size, develops around its soft protoplasm a character- 
istic membrane, and, having once established itself, 
presently begins the propagation of its species by fission. 
In those forms of organism in which spores are not 
found the germs die very rapidly unless the conditions 
for their nutrition and multiplication remain very favor- 
able. If all bacteria were of this kind, it would be 
possible to exterminate them with considerable rapid- 
ity. Spores will survive a great heat, a heat which 
will kill the organism from which the spore came; they 
will also live under a treatment with germicidal solu- 
tions which renders the bacteria inactive. In other 
words, the spores are much more resistant to the effect 
of germicides than the bacteria themselves. Cold 
does not kill them; they live through it and develop 
whenever favorable surroundings for their growth pre- 
sent themselves. They may lie dormant in the system 
for years, waking into activity only when they come into 
contact with some damaged, weakened, or diseased part 
which affords them a nest in which to develop and 
multiply, the cellular activity of the weakened part 
being unable to cope with the organisms. 

The conditions which influence the growth of bacteria 
are, first, a temperature ranging from 85 to 104 F., 
some forms requiring a higher and some a lower tem- 
perature. Some forms of bacteria are not influenced 
in their growth by the presence or absence of light. To 
some, sunlight is destructive. A few hours' exposure 
to the sun is fatal to the anthrax bacillus and to cultures 
of the Bacillus tuberculosis. The rays of the sun, how- 
3 



34 BACTERIOLOGY 

ever, must come into contact with the germs and are usu- 
ally active only on the surface of cultures. 

The majority of bacteria grow best when exposed 
to the air. Some develop better if the air is with- 
held; some will not grow at all if the least amount 
of oxygen is present. Those that grow in oxygen are 
called the aerobic bacteria, and those that will not 
grow in the presence of oxygen are the anaerobic bac- 
teria. 

A certain amount of water is always necessary for the 
growth of bacteria, though the amount required may 
be very small. If dried, no form will multiply and very 
many forms will die. 

A soil consisting of highly organized compounds is 
also necessary for their growth and multiplication, and 
slight modifications in it may prove fatal to some forms 
of bacterial life, but be highly advantageous to others. 

With age bacteria lose their strength and die. So 
we see that a suitable soil and a proper amount of light, 
heat, and air are absolutely necessary for the growth 
and development of bacteria, for they carry on all 
the functions of a higher organized life; they breathe, 
eat, digest, excrete, and multiply. 

The disease-producing bacteria effect entrance into 
the interior of the body through the skin and super- 
ficial mucous membranes, wounds, alimentary canal, 
respiratory tract, and placenta. 

The entrance of bacteria into the tissues through 
the sound skin is very rare indeed, although some 
authorities claim that infection has taken place through 
the rubbing of bacteria or their spores upon the skin. 
The dangers of infection through the broken skin are 



BACTERIA AS THE CAUSES OF DISEASE 35 

well recognized; hence every wound, no matter how 
slight, should be protected as soon as possible. 

Bacteria enter the alimentary canal through the 
food and drink. Typhoid infection has taken place 
through the rectum, its occurrence being due to the 
wearing of underclothing previously worn by typhoid 
fever patients, and to the use of enema syringe tips 
which had not been sterilized after their previous use. 

Bacteria enter the respiratory tract through the 
mouth and nose, as in a deep inspiration, or an act 
of coughing, sneezing, or the like. Pneumonia and 
tuberculosis are said to be the result of inspiration of 
the specific organisms. The direct transmission of 
bacteria from a parent to the fetus has long been a 
disputed question, but is now generally conceded. The 
micro-organisms pass through the placenta and infect 
the fetus. Tuberculosis of the ovaries, Fallopian tubes, 
and uterus may originate through the blood or from with- 
out through the vagina. Infection through the blood is 
evidenced by the general tuberculosis of all the viscera. 

The channels by which bacteria can enter the body 
are, then, very numerous; and there is scarcely a moment 
in which some part of the body is not in contact with 
them. All the disease-producing germs have their 
favorable seat in some part of the body where they grow 
more or less luxuriantly, and in the secretions and ex- 
cretions of which the chief source of their infection lies. 
The pneumonia germ prefers the lungs; the typhoid 
fever germ selects the lower portion of the small intestine ; 
the diphtheria germ, the throat; the cholera germ, the 
intestinal tract; the germ of tuberculosis prefers the 
lungs, but it is called a "medical tramp," because it will 



36 BACTERIOLOGY 

lodge in any part of the body and make its home there. 
Hence we hear of tuberculous glands of the neck, tuber- 
culous knee, intestinal tuberculosis, tuberculosis of the 
kidney, bladder, uterus, ovaries, Fallopian tubes, tuber- 
culous peritonitis, etc. A tuberculous area is always a 
danger to the system, and may infect distant organs or 
give rise to a general tuberculosis. 

To prove that a microbe is the cause of a disease it 
must fulfil Koch's circuit. It must always be found 
associated with the disease, and it must be capable 
of forming pure cultures outside the body. These 
cultures must be capable of reproducing the disease, 
and the microbe must again be found associated with 
the morbid process thus reproduced. In other words, 
we must prove the bacteria to be always present; we 
must then isolate them, then prove that they can pro- 
duce the disease in a healthy animal, and, finally, 
having succeeded in doing all this, we must prove 
that no other form of bacteria can produce the disease, 
and that where these bacteria cannot be obtained the 
existence of the disease is impossible. All these re- 
quirements have been met in many instances, and 
now there are a large number of diseases each one of 
which has been definitely proved to be caused by a 
germ of its own. a germ which produces that disease 
and no other. Most of the germs need a special train 
of circumstances in order that they may be active, so 
that, fortunately for us all, the mere presence of the 
germ itself is not sufficient to produce the disease. 
For instance, we know that diphtheria is caused by a 
germ of its own which causes that disease and no other; 
still, exposure to that germ does not invariably produce 



BACTERIA AS THE CAUSES OF DISEASE 37 

diphtheria — if it did, we should all be infected with it. 
This is because other conditions than the mere presence 
of the germs are needed to produce the disease. The 
germs must be active, and they can act only under cer- 
tain conditions. It will usually be found that the 
attack of the disease has been preceded by a local 
inflammation of the throat, thus making a suitable 
place for the specific action of the diphtheria germs. 
In typhoid fever the germs require a suitable condi- 
tion of the bowels before they can produce the dis- 
ease. This is also true of cholera, and explains why 
taking care of the health makes such a difference in 
the taking of this disease. The germs find their way 
into the body through the food and drink. Cases are 
reported that show how the germs enter drinking- 
water which is sprinkled over vegetables sold in the 
streets of cholera-infected districts, how they are car- 
ried about in clothing, and taken to articles of food 
upon the table by flies which have preyed upon chol- 
era excrement. Healthy lungs are not a suitable loca- 
tion for the development and activity of the germs of 
tuberculosis. If we are not fully in good health, or 
if we inherit a tendency to this special disease, we 
may acquire it very readily, since we often inhale the 
germs of it. Should the disease take root in our lungs, 
it may be controlled to a certain extent by a change of 
climate and surroundings; by going, for example, from 
a low and damp locality to the mild and dry atmosphere 
of Colorado, the Carolina mountains, Southern Cali- 
fornia, or of the other Southwestern States, where there 
are few cloudy days and where violent atmospheric 
changes are rare. The germs there cannot be so active, 



38 BACTERIOLOGY 

for the air is stimulating, pure, and sunlight has an 
inhibitory action upon the tubercle bacillus. The rare- 
faction of the air causes deep and strong involuntary 
respiratory movements, and there is consequently en- 
forced a better ventilation of the lungs and a better 
oxygenation of the blood, in consequence of which there 
follow more active tissue changes throughout the body 
and a strengthening of the respiratory muscles. 

On finding favorable conditions it takes germs some 
days to develop and produce the disease; this time is 
known as the period of incubation. 

The question is often asked, Why, when we are so 
constantly in contact with disease germs, do we not 
contract the diseases? All bacteria leave the body 
through the skin, lungs, kidneys, or bowels; and by a 
faithful use of disinfectants and antiseptics the germs 
may be kept confined to their original position. After 
their escape from the body they are difficult to control. 
The scales of skin or dandruff from a case of scarlet 
fever, measles, or small-pox, or the dust that arises from 
the dried sputum of a pneumonia or tuberculous patient, 
or the poisonous material which may enter our drinking- 
water from too close proximity of the well and the sewer 
into which typhoid discharges have been emptied, may 
readily be the means of propagating disease. These 
sources of infection should be scrupulously avoided. 
Another protective factor is the natural or acquired 
power of resistance to disease-producing germs. 

Immunity is either natural or acquired. Of ac- 
quired immunity we have two varieties, that which 
comes from having had the disease and artificial im- 
munity produced by injecting special antitoxins. 



BACTERIA AS THE CAUSES OF DISEASE 39 

By natural immunity is meant the natural and con- 
stant resistance to disease-producing germs. The indi- 
vidual is immune by Nature and sometimes by racial 
characteristics. Acquired immunity is a power of 
resistance attained through various circumstances. 
Thus, a single attack of some of the infectious and 
contagious diseases usually confers immunity against 
subsequent attacks. Such immunity generally follows 
an attack of typhoid fever, small-pox, scarlet fever, 
mumps, whooping-cough, measles, or yellow fever. 
Second attacks may occur; but, as a rule, a patient who 
has had an attack of one of these diseases has immunity 
for life. Influenza, pneumonia, cholera, diphtheria, and 
erysipelas are among the diseases in which one attack is 
not protective. Vaccination usually insures immunity 
against small-pox; but this is ordinarily not so complete 
or permanent as that resulting from an attack of the 
actual disease. 

Acclimatization immunity is exemplified by various 
-diseases which do not trouble natives or those long 
resident, but which may affect strangers not inured 
to the climate. 

Racial immunity is that in which certain races are 
safe from certain diseases; for instance^ negroes seldom 
suffer from yellow fever, but are more susceptible than 
whites to small-pox. It is asserted that the Arabs sel- 
dom or never have typhoid fever. An analogous exam- 
ple is afforded by the fact that white mice are not affected 
by the same diseases as the gray mice are, even though 
subjected to the same influences in respect to climate, 
food, and surroundings. 



BACTERIOLOGY 

: : ricial immunity may be produced in various 

raid that an injection of the antitoxin of 

diphtheria will give protection against the disease for 

from four to eight weeks. Tetanus has been prevented 

in a similar manner. It is impossible here to enter. 

:: in a slight degree, into the consideration of 
the many theories of immunity, since they are very 
intricate, and not one has been advanced so far that 
can clearly explain it. The theory of phagocytosis 




F|g. 4- — Phagocyte destroying a bacillus (Landerer). 

and the theory of antitoxins are the two most impor- 
tant. 

Phagocytosis is the destruction of bacteria by the 
white ceils of the blood and the cells of fixed tissues. 
The cells which eat up and destroy the germs are called 
"phagocytes." When the two meet a battle occurs, 
the bacteria fighting the cells with their active fer- 
ments, while the cells on their side put forth every 
effort to protect the body against the assaults of the 
disease. In a majority of the cases the bacteria win 
to the extent that the phagocytes die; but others take 
their place until the infection is overcome or the patient 
dies. The white blood -cells and tissue-cells having 



BACTERIA AS THE CAUSES OF DISEASE 41 

thus been educated to withstand the poison, their de- 
scendants inherit this capacity and are born insusceptible. 
This theory was suggested by Carl Roser in 1881. 
Sternberg and Koch afterward put forth the same 
view, but it is usually credited to MetschnikorT, who 
published his observations in 1884. 

The other theory — the so-called antitoxic theory — 
is founded on numerous more or less convincing ex- 
periments. If an animal be injected with certain 
pathogenic bacteria or their toxins in gradually as- 
cending doses, it can be immunized to doses that under 
other circumstances would prove fatal. The blood- 
serum of an animal thus immunized has the power, 
when injected into another animal, of rendering it also 
immune to the bacteria that have originally been used; 
and in some cases the serum is even capable of curing 
the disease after it has developed in another animal. 
These properties with which the blood-serum has become 
endowed depend upon the presence of what are called 
antitoxins and antibacterial bodies. In man also, after 
recovery from certain infectious diseases, it is possible 
to demonstrate in the blood-serum the presence of 
antitoxic substances; and it is now the general be- 
lief that immunity, at least of the acquired form, is 
due to such antitoxins. The uses and practical pre- 
paration of antitoxins will be described in the next 
chapter. 

The most important of the special surgical micro- 
organisms — i. e., those most frequently met with in 
surgical work — are the following, the majority being 
pus producers: 



42 BACTERIOLOGY 

1. Staphylococcus Pyogenes Aureus. — This is the most 
common form ; it is quickly killed by carbolic acid (i : 20), 
bichlorid of mercury (1 : 1000), or by a few moments' 
boiling. It is found in the mouth, alimentary canal, and 
under the nails; it lives in the eyes, nose, ears, mouth, 
in the superficial layers of the skin, and is distributed in 
the water, soil, and air, especially in the dust of houses 
and surgical wards where the proper precautions are not 
taken. 

2. Streptococcus pyogenes is a most important patho- 
genic micro-organism, and is thought by many authori- 
ties to be identical with the streptococcus of erysipelas. 
The Streptococcus pyogenes is frequently associated 
with internal diseases, and has been found in the uterus 
in cases of infective puerperal endometritis, ulcerative 
endocarditis, acute septicemia, and other diseases. It 
is one of the most common causes of postoperative 
peritonitis. 

3. The Bacillus coli communis is always present in 
the intestines, and, while ordinarily active in the proc- 
esses of digestion, it is thought to be a frequent cause 
of acute suppurative peritonitis. 

4. The Staphylococcus pyogenes albus resembles the 
aureus in form, but is less virulent. It is a common 
cause of suppuration, and although it has been found 
alone in acute abscesses, it is usually associated with 
other pyogenic cocci, chiefly the Staphylococcus pyog- 
enes aureus. 

5. The Staphylococcus epidermidis albus is a micro- 
coccus which is almost always present upon the 
skin, not only upon the surface, but also in the outer 
layers. 



BACTERIA AS THE CAUSES OF DISEASE 43 

6. The Staphylococcus pyogenes citreus is not quite 
so common nor so pathogenic as the other forms, and 
is less important. 

7. The Bacillus pyocyaneus exists in pus (especially 
in open wounds), and gives to it a peculiar bluish or 
greenish color. 

8. The Bacillus aerogenes capsulatus is a gas-pro- 
ducing bacillus that sometimes causes death after 
operations on the uterus; it may also enter through 
accidental wounds. 

9. The Bacillus tuberculosis is the cause of all tuber- 
culous processes. The chief cause of the spread of 
infection is found in the dried sputum, which becomes 
pulverized and is then inhaled as dust; and since one 
patient may expectorate as many as four billion bacilli 
in twenty-four hours, his capacity for harm is very 
considerable. The bacilli retain virulence for five months 
in dried sputum, and in putrid sputum for forty-three 
days. 

10. The Micrococcus lanceolatus, known also as 
Streptococcus lanceolatus, pneumococcus, and Diplo- 
coccus pneumoniae, is the cause of croupous pneu- 
monia and of many of the acute inflammations of the 
serous membranes of the body. It is also a pus pro- 
ducer, and has been found in empyema and acute ab- 
scesses. 

11. The bacillus of tetanus is found particularly in 
garden-soil, in the dust of halls, walks, cellars, street- 
dirt, and in the refuse of stables. It is not a pus 
producer. Tetanus is a disease due to the absorption 
of its toxins, which poison the nervous system pre- 
cisely as would dosing with strychnin. 



44 BACTERIOLOGY 

12. The diphtheria bacillus causes the dreaded dis- 
eases diphtheria and membranous croup, as well as 
inflammations of the eyes and nose; at times it also 
attacks open wounds. 

The Spirochceta pallida is the cause of syphilis and it is 
transmitted usually by direct inoculation from one 
infected with the disease, the primary and secondary 
lesions being most infectious. 



CHAPTER III 

THE THEORY OF ANTITOXINS 

Great progress has been made of late in the field 
of serum-therapy, though much remains open to ques- 
tion and many recorded facts cannot yet be explained. 
The field for the investigator is perhaps larger than 
ever before. For a better understanding of the sub- 
ject of antitoxins and their therapeutic application, a 
few essential facts should be borne in mind. An anti- 
toxin is not the direct result of bacterial action, but 
is properly described as an unknown body resulting 
from the resistance of the healthy organism to the 
toxins of pathogenic bacteria. According to the pre- 
vailing theory, antitoxins are the products of the body 
cells, formed under the influence of the bacterial toxin. 
In therapeutic practice the antitoxic body comes to us 
in the blood-serum of an animal, usually the horse. 
When properly prepared and kept in aseptic con- 
tainers the antitoxins are not at all dangerous; they 
are as innocuous as an equal amount of blood-serum 
administered in the same way. Antitoxins are used both 
to counteract the effects of the toxins which are elabor- 
ated by pathogenic bacteria in the body, and to render 
the system immune, so that it may resist the action of the 
bacteria should they gain access to the body. The 
antitoxins do not destroy the bacteria; in other words, 
they are not germicides. In fact, the antitoxic serums 

45 



46 BACTERIOLOGY 

are themselves good culture-media. One theory of 
their action is that they neutralize the toxin, thus giving 
the natural bactericidal powers of the body an oppor- 
tunity to exercise their function. 

The following is a brief description of the process 
employed in the laboratory of Parke, Davis & Co. for 
the preparation of diphtheria antitoxin: 

Young horses in perfect condition are selected and 
kept under careful observation by an expert veterina- 
rian for three or four weeks. During this time they 
are carefully tested with tuberculin for the possible 
existence of unsuspected and undeveloped tubercu- 
losis, and with mallein for glanders. When a horse 
is found to be perfectly healthy it receives its first 
dose of diphtheria poison or, more properly, a solution 
of the toxin of the diphtheria bacillus. This is pre- 
pared in the following manner: A culture is obtained 
from the throat of a patient suffering from a virulent at- 
tack of diphtheria. The diphtheria bacillus is isolated 
from this culture and planted in a flask of bouillon 
or beef-tea, which is then kept in an incubator from 
three to four weeks. At the end of this time it has 
attained its maximum toxicity and the bacteria begin 
to die of their own poison. The toxin which they have 
elaborated in the course of their existence is held in 
solution in the beef-tea. This bouillon solution of toxin 
is then filtered through porcelain to remove the bacterial 
cells and any other extraneous matter. It is then ready 
for injection into the horse. About T V of I c.c. is injected 
intravenously. The horse responds with all the consti- 
tutional symptoms of diphtheria, such as a chill, fever, 
loss of appetite, more or less pharyngeal paralysis, 



THE THEORY OF ANTITOXINS 47 

with regurgitation of food. Sometimes death occurs 
from heart paralysis. Upon recovery, which comes 
within a few days, a slightly larger dose is given. This 
treatment is continued for about one year, at the end of 
which time the horse will take from 2000 to 3000 times 
the initial dose without reaction. It is then ready for 
bleeding. About 6000 c.c. of blood are drawn from the 
external jugular vein. This is allowed to clot, and the 
serum obtained is known commercially as antitoxin. 
It is customary to add an antiseptic, such as trikresol, 
to preserve the serum. 

In preparing the streptococcus antitoxin a culture 
is made of bacteria obtained from two sources — ery- 
sipelas and puerperal septicemia. This is done because 
some eminent bacteriologists believe that the strepto- 
coccus of erysipelas is not identical with the streptococcus 
of puerperal fever. It is but fair to say, however, that 
others equally eminent assert the identity of the two 
streptococci. To meet the possibility of the non-iden- 
tity of the organisms a culture obtained from the two 
sources is used. Its virulence is increased by passing 
it through rabbits. After passing through about fifty 
rabbits a culture is planted in beef -tea, and the same 
course pursued as for diphtheria antitoxin. Antitubercle 
serum is obtained by immunizing horses with the original 
Koch's tuberculin. 

As to the therapeutic action of antitoxin, little or 
nothing is known positively. It seems reasonable to 
conclude from experimental evidence that the anti- 
toxin neutralizes the toxin in the body and thereby 
gives the natural germicidal powers an opportunity 
to dispose of the bacteria. It may be that it has the 



48 BACTERIOLOGY 

additional property of stimulating the phagocytic and 
possibly other bactericidal functions. The following 
experiments made by Martin and Cherry, of Mel- 
bourne, - Australia, and described in the Jour. Amer. 
Med. Assoc, of August 27, 1898, are of interest in 
this connection. Behring, Ehrlich, and Kanthack have 
advocated the theory that the antagonism between 
toxins and antitoxins is a chemical one, somewhat anal- 
ogous to the neutralization of an acid by an alkali; 
while Buchner, Metschnikoff, and others have main- 
tained that it is indirect and operates through the 
cells of the organism. Martin and Cherry used a 
snake-venom antitoxin. A large number of guinea- 
pigs were used. At 6o° C. the antitoxin was destroyed, 
while the venom retained its virulence. In the con- 
trol-experiment with the venom only all the animals 
died within a few hours. A number of mixtures were 
made of 1 c.c. of antitoxin with twice the fatal dose 
of venom; others with three or four times the fatal 
dose. These mixtures were allowed to stand at the 
usual laboratory temperature (20 to 23 C.) for two, 
five, ten, fifteen, and thirty minutes respectively, then 
heated to 68° C, and afterward injected. 

As remarked above, this heat destroyed the anti- 
toxin, so that none was injected. The animals sub- 
jected to the mixture of the stronger doses of ten min- 
utes or less died or were seriously affected; all of those 
receiving the fifteen-minute mixture survived; while 
the thirty-minute mixtures produced no symptoms 
whatever. Similar results were obtained with diph- 
theria antitoxin and toxin. These experiments seem 
to show, as far as anything can, that the neutraliza- 



THE THEORY OF ANTITOXINS 49 

tion of toxins may occur in the test-tube, and that the 
vital processes in the organism and the body cells are 
not essential. These gentlemen made further exper- 
iments by passing a mixture of toxins and antitoxins 
through a Pasteur-Chamberland filter. This was po- 
rous for toxin, but not for antitoxin, owing to the dif- 
ference in the size of their molecules. The toxin which 
passed through the filter, after having been mixed with 
antitoxin, was neutral. The unavoidable conclusion 
from this experiment is that the toxin was neutralized 
before filtration. 

Experiments have been tried in order to prove the 
theory that toxins are albumoses and antitoxins globu- 
lins; but these experiments do not appear to be con- 
clusive as to this point. 

The supposition that the administration of antitoxin 
is followed by a stimulation of the germicidal powers 
of the body seems to be reasonable, at least in the 
case of the antistreptococcic serum, since the strepto- 
cocci disappear with the passing away of the signs 
and symptoms. On the other hand, the Klebs-Loff- 
ler bacillus is found in the throat for weeks and even 
months after the disappearance of all symptoms of 
diphtheria in cases treated with the antitoxin. 

The present status of diphtheria antitoxin may be 
presented in a few words: It has established itself as 
a specific in the treatment of this disease. During the 
past few years the use of larger doses has become more 
general, and it seems certain that better results were 
obtained. The administrators of the Chicago Depart- 
ment of Health give 2000 units in all cases of suspected 
diphtheria, and employ 1000 units as an immunizing 
4 



50 BACTERIOLOGY 

dose. During the months of November and December, 
1898, this department treated 219 cases of bacteriologic- 
ally proved diphtheria — all charity cases — with a death- 
rate of 4.1 per cent. Some years ago. when antitoxin 
was not used, the death-rate from diphtheria treated by 
this department was about 35 per cent. 

Antistreptococcic serum gives promise of being 
second only to the diphtheria antitoxin in point of 
therapeutic value. It has been most successful in 
erysipelas and puerperal septicemia. Cases of scarlet 
fever are reported in which it has been useful in short- 
ening the duration of the disease and in preventing 
unfortunate complications and sequelae, such as otitis 
media and other suppurative processes due to strepto- 
cocci. 

A mixture of the toxin of the streptococcus of ery- 
sipelas and the products of a harmless germ, the Bacillus 
prodigiosus, is used by Coley and others as an injec- 
tion in malignant tumors that are past the stage of 
operation or are so situated that an operation is im- 
possible. 

Tetanus antitoxin is valuable as a prophylactic treat- 
ment, and if used in large doses in the early stages it is 
the best known method for the treatment of tetanus. 
The antitoxin may be introduced subcutaneously, intra- 
venously, and intradurally. Small doses are practically 
valueless, but large and repeated doses are very successful. 

Antityphoid vaccine has now practically prevented 
typhoid fever, but it is useless as a therapeutic agent. 

Antitoxin in cerebrospinal meningitis is given intra- 
durally and is moderately successful, especially if given 
early. 



THE THEORY OF ANTITOXINS 5 1 

Flexner's serum in infantile palsy is at present being 
tried. It is apparently very successful if given early. 

The antitubercle serum has not shown itself to have 
more value than a great number of other remedies 
vaunted as specifics in tuberculosis. 

Method of Injecting Antitoxin. — The serums and 
toxins are given hypodermically, the injection being 
made into the back, thigh, side of the breast, or over 
the chest. Perfect antisepsis for the operation is 
absolutely necessary. The puncture wound is closed 
with a collodion dressing. It is not necessary to use 
massage for the purpose of causing more rapid ab- 
sorption of the injected serum — the swelling gener- 
ally disappears in a short time of itself. Sometimes 
the site of the injection becomes very painful. In 
certain cases pains in the joints and various skin 
eruptions (erythema, hives) develop after the injec- 
tion. They are not of great moment, but the physi- 
cian's attention should be called to them. 

The reaction following an injection of Coley's mixture 
is sometimes severe, and may correspond to the symp- 
toms beginning an attack of erysipelas — chill, local 
redness, and high temperature. 

Within the last few years certain serum reactions have 
developed. By the use of these methods the presence 
or the absence of a disease is detected. For example, 
syphilis, the presence or absence of it may be deter- 
mined by a complicated serologic reaction called the 
Wassermann test. To obtain blood for this test the 
finger is stuck with a blood sticker and the blood pressed 
into a test tube until it is three-quarters full. A test 
for gonorrhea is used, but it is not entirely satisfactory. 



52 BACTERIOLOGY 

For detecting the presence or absence of tuberculosis, we 
have three tests: (i) Tuberculin test, which is made by 
scarifying the skin and rubbing in tuberculin. This 
gives a cutaneous reaction in forty-eight hours if the 
disease is present. (2) Tuberculin is injected subcu- 
taneously, and the temperature is taken every hour for 
forty-eight hours. If tuberculosis is present there will 
be a marked rise in the temperature. (3) Yon Pirquet 
test : This method consists in dropping tuberculin into the 
conjunctiva. If the test is positive the conjunctiva 
becomes reddened. The Widal test consists in mixing a 
small amount of the blood-serum of the patient with a 
pure culture of typhoid bacilli. If typhoid fever exists 
there will be clumping or agglutination of the bacilli. 



CHAPTER IV 

ANTISEPTICS, DISINFECTANTS, AND 
DEODORANTS 

Articles and wounds which are entirely free from 
bacteria and their spores are termed aseptic or sterile. 

An antiseptic is a substance which kills or retards the 
growth of bacteria. 

A disinfectant or germicide is a chemical or physical 
agent which destroys the vitality of bacteria. 

Excessive heat, dry or moist, is a disinfectant because 
it kills bacteria; while cold retards growth, but does not 
kill bacteria. 

A deodorant is a substance which destroys offensive 
odors. 

Occasionally a substance possesses all three qualities, 
as carbolic acid. In strong solution (5 per cent.) it is a 
germicide; in 1 or 2 per cent, it is an antiseptic. Its 
natural odor makes it a good deodorant. 

The power of a chemical agent to destroy bacteria 
depends on: 

(1) The kind of bacteria; some being easily killed by 
an agent which is harmless to others. Spore-forming 
bacteria are very resistant, and the spores are much 
more resistant than the bacteria. 

(2) The number of bacteria present. 

(3) The temperature of the disinfecting agent. The 
higher the temperature, the more powerful the agent. 

53 



54 ANTISEPTICS 

(4) The strength of the solution, no matter of what 
substance. The stronger the solution, the more powerful 
the agent. 

(5) The nature and character and quality of the as- 
sociated material. If they are contained in a large 
amount of organic material, such as sputum or fecal 
matter, the chemical agent may combine with these and 
may thus be converted into an ineffective material before 
it has had an opportunity to act on the bacteria. 

The agents capable of destroying bacteria are chem- 
icals, physical and mechanical. The chemical agents are 
numberless; but there are many which cannot be em- 
ployed because they are too weak or act too slow, are 
too poisonous, are too destructive to objects with which 
they come in contact, or are too expensive for general use; 
for example, corrosive sublimate or mercuric bichlorid 
cannot be used for sterilizing instruments because it cor- 
rodes and blackens them. Potassium permanganate 
stains everything it comes in contact with. 

Some forms of physical agents cannot be used in 
certain instances; for example, boiling water, steam, 
or hot air could not be used to sterilize a surgeon's 
hands. 

For practical purposes the term "disinfection" is used 
for the action of chemical agents, and the term "steriliza- 
tion" for physical agents such as heat. 

Among all agents, both chemical and physical, heat is 
entitled to the first place, and fire, though seldom practi- 
cal, is superior to all others. Fire should always be used 
to destroy old clothing, books, and playthings that have 
been in contact with patients suffering from infectious 
diseases. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 55 

Heat is used in the form of hot air, steam, and boiling 
water. 

Boiling water kills most germs on contact, and the 
more resistant types are killed by it in one or two minutes ; 
for example, spores of anthrax. 

Steam is the next most powerful agent. It is more 
penetrating than hot air, but the air must be saturated 
with it for it to exert its full influence. Steam is used in 
four forms: 

Simple Steam. — Quiescent. 

Live Steam. — Circulating. 

High-tension Steam. — Under pressure. 

Superheated Steam. — That which has been secondarily 
heated to ioo° C. 

Live steam destroys anthrax spores in from five to 
fifteen minutes. 

Disinfection by steam is applicable to clothing, linen, 
blankets, towels, surgical dressings, instruments, cur- 
tains, carpets, brushes, mattresses, pillows (the two latter 
should be ripped open) , and a number of delicate fabrics. 
It is not applicable to linen soiled by feces, blood, or pus, 
since the stains would become fixed by the process (soak 
first in plain cold water), nor to rubber articles. Under 
certain conditions many articles are exposed to the action 
of steam for one hour on three successive days, being kept 
during the intervals at a temperature of 70 to 8o° C. to 
favor the development of bacteria. This is called "inter- 
mittent" or "fractional" sterilization, the object of which 
is to kill all bacteria that may have developed from 
spores that escaped the first steaming. The last steril- 
ization is for the purpose of making sure. 

Hot air is inferior to both steam and hot water. 



56 ANTISEPTICS 

Steam at a temperature of ioo° C. is more effectual 
than hot air at a much higher temperature. Accord- 
ing to investigations, exposure to a temperature of 
150 C. (302 ° F.) for one and a half hours in a hot-air 
sterilizer will kill all known bacteria and their spores. 

The most prominent chemical germicides in use now 
are: 

1. Bichlorid of mercury. 

2. Tincture of iodin. 

3. Carbolic acid. 

4. Potassium permanganate. 

5. Alcohol. 

6. Creolin. 

7. Lysol. 

8. Harrington's solution. 

9. Argyrol. 

10. Hydrogen dioxid. 

11. Chlorid of lime. 

(1) Corrosive sublimate or bichlorid of mercury has, 
like carbolic acid, the advantage of being both effica- 
cious and cheap. It has the disadvantages that it 
is decomposed by alkalies, that it is precipitated by 
albumin, and that it corrodes metals. It is used in 
strengths of from 1 : 10,000 to 1 : 500. The solution 
should be made as it is needed, because in old solu- 
tions most of the soluble corrosive sublimate has been 
converted into insoluble calomel, and the solution is 
not germicidal. By using the compressed tablets now 
on the market fresh solutions are readily made. A 
tablet usually contains the requisite amount of corrosive 
sublimate to make when added to 1 pint of water a 
1 : 1000 solution, and by increasing or diminishing the 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 57 

amount of water the strength of the solution may be 
altered at pleasure. The tablets are very convenient, 
and almost compel accuracy in the preparation. Cor- 
rosive sublimate is of less value for the disinfection of the 
excreta than carbolic acid, as it hardens the albuminous 
material which covers the outside of all fecal masses, and 
thus' protects the inside from the desired action. Tar- 
taric acid, chlorid of sodium, or chlorid of ammonium is 
often added to prevent this. Compressed tablets, each 
containing tartaric acid or ammonium chlorid and 7J 
grains of corrosive sublimate, or equal parts of chlorid of 
sodium and corrosive sublimate, are in common use. 
The convenient form in which this drug is put up and the 
readiness with which it can be used in surgical and 
medical work have made its adoption universal. Its 
poisonous character must be kept constantly in mind. 
The first symptoms of poisoning in consequence of the 
absorption of the bichlorid are profuse salivation, fetid 
breath, a metallic taste in the mouth, sore teeth, spongy 
gums, and swollen tongue. Should any of these symp- 
toms appear they should at once be reported to the sur- 
geon. As the solution has no odor, it is occasionally 
swallowed in mistake. Should this occur, symptoms of 
a violent gastro-enteritis appear — vomiting, burning 
pain, bloody stools; the kidneys are also affected and an 
acute Bright's disease develops. The immediate treat- 
ment of this acute poisoning consists in the giving of 
white of egg, flour or milk and lime-water, and washing 
out of the stomach. 

(2) Tincture of iodin is made by dissolving iodin crys- 
tals in 95 per cent, alcohol, the amount of the latter used 
indicating the strength of the solution: 7 per cent, tine- 



58 ANTISEPTICS 

ture is the standard and is the strength most commonly 
used; i, 3, and 5 per cent, solutions are also used for 
various conditions. 

This antiseptic is the most common in use for prepar- 
ing the field of operation, disinfecting wounds, and as a 
dressing solution in weaker strength. Nearly every 
surgeon will agree that every lacerated, incised, punc- 
tured, or stab wound occurring accidentally should be 
swabbed out with tincture of iodin. So, should you be 
present and called on to treat any such accident in the 
absence of a physician, use tincture of iodin before apply- 
ing a dressing. 

(3) Carbolic acid is a coal-tar product derived by dis- 
tillation. When pure it is a solid white or faintly rose- 
colored, crystalline body, soluble in water, alcohol, or 
glycerin. On exposure to air it absorbs 5 per cent, of 
moisture. 

In making a solution of carbolic acid it is dissolved in 
hot water and shaken thoroughly. In solution it is used 
more to disinfect instruments and floors of operating 
rooms than for dressings or treatment, except in the 
dressings of furuncles immediately after incision; pure 
carbolic acid is used here to disinfect the tissues after 
incision. It has the advantage over corrosive sublimate 
in that it does not discolor instruments or clothing. 
Dilute carbolic acid is a reliable disinfectant for instru- 
ments. If an instrument that is indispensable hap- 
pens to fall to the floor during an operation, it may be 
laid for a moment in pure carbolic acid, then rinsed 
with sterile water, and it is ready for use. Long- 
continued submersion in the acid will, however, de- 
prive knives and scissors of their temper and edge. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 59 

It is not used to any great extent in general dressings 
because it irritates and causes a numbness of the skin. 
Symptoms of poisoning have been produced by the 
absorption of the drug from surgical dressings and 
from the use of carbolic solutions for irrigation. The 
first evidences of poisoning are a very dark greenish 
or a blackish coloration of the urine, headache, giddi- 
ness, ringing or singing in the ears, and lassitude. The 
odor of carbolic acid is, to a certain extent, a protect- 
ive against accident; yet fatalities occasionally oc- 
cur. The antidotes of carbolic acid are alcohol, milk, 
and lime-water, or flour and water. The strength of the 
solutions used varies from I : 80 to 1 : 20. The acid 
is bought usually in the liquid form, having a strength 
of 95 per cent. To make a solution 1 : 20 (5 per cent.), 
1 : 40 (2J per cent.), 1 : 50 (2 per cent.), 1 : 80 (ii per 
cent.), 1 ounce of the 95 per cent, solution is added 
to 20, 40, 50, or 80 ounces of water. When obtained 
in the solid form, it may readily be liquefied by placing 
the bottle in a vessel of hot water. 

Other coal-tar derivatives which are akin to carbolic 
acid, but less powerful as disinfectants and less poisonous 
are: creolin, lysol, sozal, and saprol, the two latter being 
very rarely used. 

(4) Potassium Permanganate. — This drug is an anti- 
septic, disinfectant, and deodorant. It depends for its 
action on its oxidizing properties. In contact with or- 
ganic substances it parts with its oxygen very readily and 
becomes inert. Its chief disadvantage is that it stains 
everything a brownish-black color. It is used usually in 
strengths of 1 : 100 to 1 : 10. It was formerly used quite 
extensively to sterilize the hands. The stain it leaves on 



60 ANTISEPTICS 

the hands may be removed by oxalic acid solution. It is 
rounds, especially those which have an 
offensive odor, acting as a deodorant as well as an anti- 
septic. It is also used to disinfect bowel movements and 
to flush water-closets. It shows by its changing from a 
reddish purple to brown whether it is acting or whether 
it is exhausted. 

5 Alcohol. — Absolute alcohol is an antiseptic and 
disinfectant used for cleansing and sterilizing the skin, 
for preparation of sutures and ligatures, and for steril- 
izing :r.s:ruments. Alcohol is used by some surgeons in 
the preparation of the patient for operation, and it makes 
an excellent dressing medium for fresh wounds which have 
been sutured. 

(6) Creolin and (7) Lysol are both coal-tar deriva- 
tives. They are used chiefly by obstetricians and gyne- 
cologists. When mixed with water they make a soapy, 
oily solution very suitable for vaginal douches because 
they do not irritate the canal. Lysol ordinarily is used in 
from 1 to 3 per cent, solutions, but when repeated vaginal 
douches are ordered 0.50 per cent. (f per cent.) solution 
is the maximum that the average patient will tolerate. 
Creolin is less irritant and probably less germicidal. 

(8) Harrington's Solution. — This solution, designed by 
Harrington, of Boston, is becoming more commonly used. 
It is an excellent disinfectant for the field of operation 
and for hand sterilization. Its capacity for destroying 
bacteria is twenty times greater than any known gerr 
and it is no more irritating than any other drug of this class. 
Hands washed in this solution for one minute become 
sterile, so that no bacterial growths can be obtained from 
the scrapings made from such hands. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 6l 

The following is the formula: 

Bichlorid of mercury gr. xlviij; 

Hydrochloric acid § viij ; 

Aqua destillata Oiiss; 

Alcohol Oiiss. 

(9) Argyrol is a definite chemical compound of silver 
containing 30 per cent, of that metal. The various com- 
binations of silver possess more or less antiseptic qualities 
and are irritating to the tissues to a greater or less extent. 
But the preparation is very efficient as an antiseptic and 
practically non-irritating. It is not precipitated by al- 
bumin or sodium chlorid. It is used chiefly in infections 
of the mucous membranes in solutions varying from 2 to 
50 per cent. Solutions should be made fresh, as it 
deteriorates rapidly. 

The stains are best removed by washing the materials 
in a solution of bichlorid of mercury. 

(10) Hydrogen dioxid is useless when employed as an 
antiseptic or disinfectant because it has no such prop- 
erties. The sphere of its usefulness lies in the fact that 
it eliminates its oxygen freely when in contact with or- 
ganic matter. It is therefore used to remove blood-clots, 
necrosed tissue, and other debris in wounds and ulcers. 
It possesses some hemostatic qualities and may be used 
in minor venous oozing. 

(11) Chlorid of lime, when mixed with carbonate of 
soda and moistened with water to form a paste, elim- 
inates chlorin gas, which possesses antiseptic qualities. 
Some surgeons use this combination for hand sterilizing. 

Other less prominent antiseptics are : 
(1) Formaldehyd. — It is a gas formed from the partial 
oxidation of wood alcohol. It is more commonly 



62 



ANTISEPTICS 



used as a disinfectant than for treatment purposes. It is 
very commonly used by health officers in gas form to 
fumigate rooms after infectious diseases. In solution, 

which is made by dissolving 
the gas in water, it is used for 
disinfecting floors and walls, 
especially of operating rooms. 
Its disadvantages are: after 
using the solution on the skin 
the latter begins to smart and 
burn. Its vapors are irritat- 
ing to the lungs, eyes, and 
nostrils. It is a very power- 
ful germicide, being superior 
to bichlorid of mercury. 

(2) Iodoform, a yellow 
powder with a penetrating 
odor, derives its antiseptic 
properties from the fact that 
it eliminates iodin. On clean 
wounds which exude serum 
it does good by absorbing the 
serum, thus removing good 

Em M p > culture-media for bacterial 

m & i J0 growth. It prevents decom- 

position, and inhibits the 
-Formaldehyd generator. ^.^ q( hm ^ ^ dg _ 

stray pus-producing bacteria. By absorption from a 
large wound surface it sometimes produces poisoning, 
as evidenced by headache, loss of appetite, elevation of 
temperature and pulse, restlessness, and insomnia. In 
severe cases a fine macular eruption appears on the face 




ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 63 

and limbs. Some patients are very susceptible to it. It 
is used in the form of iodoform gauze for dressings, iodo- 
form ointment, as a dusting-powder, and dissolved in ether 
or sterile oil for injecting sinuses and tuberculous abscesses. 

(3) Aristol (thymol-iodid) is a dusting-powder with action 
similar to iodoform, but without the disagreeable odor. 

(4) Boric Acid. — As a powder and in solution it is a 
mild antiseptic very commonly used. Its most impor- 
tant seat of usefulness is in eye work and for irrigations 
of the bladder. 

It is a non-poisonous, white, odorless powder, and for 
this reason is preferred to other dusting-powders. 

To get the best effect it must be in a saturated solution. 

(5) Oxalic acid is a powerful germicide, but is not com- 
monly used now except to remove the stains left by potas- 
sium permanganate. At a temperature of 40 C. it is 
a very powerful germicide. It irritates the skin, but this 
can in a measure be avoided by immersing the hands and 
forearms in cold water or lime-water. 

Abuses of Antiseptics and Germicides. — This class of 
drugs has been more abused than any other in the ante- 
and postoperative treatment and management of sur- 
gical cases. They are useful and necessary in their place, 
but their place is limited. The cleaner a surgeon or nurse 
is surgically, the less they will use antiseptics. In in- 
fected wounds and other cavities the greater the infection, 
the milder the solution and the greater the quantity 
should be used ; cleanse the wound by removing all ne- 
crotic and foreign material before applying your anti- 
septic. 

Contrarily, strong solutions should be used for the 
surgeon's hands and for the field of operation. 



6 4 



ANTISEPTICS 



ANTISEPTIC SOLUTIONS 

Approximate Ways of Making Antiseptic Solutions by Apothe- 
caries' Measure 



To make — 














i oz. of 


a i 


500 


solution 


use 1 gr. 


of the drug 


ipt. ' 


' i 


.500 


11 


" 15 gr- 


a 


' 


iqt. ' 


' i 


: 500 


a 


" 30 gr. 


" 


' 


iqt. ' 


' i 


: 1000 


" 


" 15 gr- 


" 


' 


iqt. ' 


' i 


: 2000 


" 


" l\ gr- 


" 


c 


iqt. ' 


' i 


•.3000 


" 


" 5 gr- 


" 


' 


iqt. ' 


' i 


: 4000 


" 


" 3l gr- 


(( 


« 


iqt. ' 


' i 


: 5000 


<< 


" 3 gr- 


(< 


' 


iqt. ' 


1 i 


: 10,000 


" 


" i| gr. 


" 


( 



Percentage Solutions (Approximately) 



To make — 

1 dram of a 1 per cent, solution use \ gr 

2 



1 dram 
1 dram 
1 oz. 
1 oz. 
I oz. 



2fgr 

" " 5 gr 

" 92 gr 

" 19 gr 

Metric System 



+ of the drug. 



Solids. Approximate 

equivalent. 

1 grain 0.065 gram. 

1 ounce 30.000 grams. 

1 pound 500.000 grams. 



Liquids 

1 minim. 
1 ounce. 
1 pint. . . 
1 quart. . 



Approximate 
equivalent. 

0.06 c.c. 

30.00 c.c. 

500.00 c.c. 

1000.00 c.c. or 1 liter. 



Examples 
To make— 

1000 c.c. (1 liter) of a 1 : 500 solution use 2 grams of the drug. 
1000 c.c. " " 1 : 1000 " " 1 gram " 

1000 c.c. " " 1 : 2000 " " \ gram " 

Labarraques solution is a solution of chlorinated 
soda, and is made from chlorinated lime and sodium 
carbonate. It is used as an antiseptic in solutions of 
1 : 10, and for cleansing purposes. 



PART II 
SURGICAL TECHNIC 



CHAPTER V 

BANDAGING AND DRESSINGS 
BANDAGING 

A nurse will be frequently judged by her ability to ap- 
ply a bandage properly. 

Materials. — They may be of unbleached muslin, gauze, 
black or white, flannel; crinoline, or gauze for plaster-of- 
Paris; or rubber. 

Muslin purchased in large rolls is cut in lengths of 
from 6 to 8 yards. The end of the muslin is cut in 
the desired widths for bandages and torn in strips. 

Rolling by Hand. — One end of the bandage is folded 
upon itself several times and rolled between the thumb 
and first finger of the left hand until it becomes firm 
enough to hold between the fingers. The folded por- 
tion is held between the thumb and index finger of the 
left hand and rotated by the thumb and second finger 
of the right hand. 

The bandage machine consists of an upright and 
octagonal shaft mounted upon a metallic base which 
may be screwed to a table. The shaft is turned by hand 
5 65 



66 SURGICAL TECHNIC 

or foot, depending upon the type of machine used. The 
width of the space on the shaft is regulated by a movable 
upright. The bandage is fed to the roller by the left 
hand. It should be rolled tense, and when the bandage 
is finished the crank is reversed automatically, releasing 
the bandage from the shaft, allowing it to be pulled out 
(Fig. 6). 

It is now considered cheaper to buy bandages already 
rolled in yard lengths and cut as needed (Fig. 7). 




Fig. 6. — Hand roller-bandage machine. (Fowler's Surgery.) 

Application of Bandage. — Bandages are used to hold 
splints and dressings in place, to give support as in frac- 
tures. They should be applied moderately tight. If 
support is the motive, a number of turns will secure this 
much better than a few tight ones. It is much better to 
apply a bandage too loosely than too tightly. 

In applying wet dressings, always remember to allow 
for shrinkage. A bandage is started by placing the outer 
surface of the initial extremity upon the starting-point 
and holding it with index-finger of the left hand. With 



BANDAGING AND DRESSINGS 



67 



the roller held in the right hand, two turns are made in 
the direction which the bandage is to take. 

To overlap is to make a second turn cover a certain 
portion of the preceding turn. This is the procedure in 
all spiral bandages. 

To recur is to catch a turn at some point and turn it in 
such a way so that it either exactly retraces its course or 
turns off slightly in another direction. 




Fig. 7. — Mitre box and Christy knife for cutting bandages. 
Operating Room and the Patient.) 



(Fowler's 



To Reverse. — The bandage is turned laterally upon 
itself, so that the part that was external is now internal. 
This is performed by holding the bandage in place with 
the thumb of the left hand, slightly relaxing the roller 
while pronating the right hand (Fig. 8). The thumb is 
now removed and the bandage tightened and continued 
around the part until the second reverse is reached, where 
the same procedure takes place. It is very necessary to 
have the turns in alignment. This may be made in the 
opposite direction, i. e., descending or ascending. The 



68 



SURGICAL TECHNIC 



object of reversing a bandage is to adapt it to the change 
in diameter of the part. 

To Secure. — The end of the bandage is split into two 
tails. These are passed in opposite directions around 
the part and tied in place. The end of the bandage may 
also be pinned, but great care should be used so that the 
pins do not penetrate the bandage and stick into the part. 










: .'V;. ; 



Fig. 8. — Making the reverse. (Fowler's Surgery.) 

Removal. — Each turn should be taken off reversely 
from the way it was put on. 

There are three general types of bandage, of which all 
others are modifications: circular, spiral reversed, and 
figure-of-8. 

Barton's Bandage (2 inches by 6 yards). — The initial 
end of the roller is placed on the head under the mastoid 
process and the bandage is carried upward and in front 
of the parietal eminence, across the vertex of the skull, 



BANDAGING AND DRESSINGS 69 

downward in front of the ear, under the chin, upward in 
front of the opposite ear, over the top of the head, where 
it crosses the first turn and back to the starting-point. 
The bandage is then continued forward below the right 
ear, in front of the chin, and back to the starting-point. 
These turns should be continued until the end of the 
bandage is reached. 




Fig. 9. — Barton's bandage. (Fowler's Surgery.) 

Secure with adhesive plaster or pins introduced where 
the bandage crosses. In applying this bandage great 
care should be taken to see that each turn overlaps the 
preceding turn and that the bandage crosses in the me- 
dian line of the skull (Fig. 9). 

Uses. — To retain dressings on face, fractures and dis- 
locations of lower jaw. 

Gibson's Bandage (2 inches by 5 yards). — This ban- 
dage consists of three turns from the occiput to the fore- 
head and back again. On the final turn the bandage, is 
reversed as it reaches the front of the ear. It is then 



70 SURGICAL TECHXIC 

carried downward under the chin, thence up on the op- 
posite side, and back to the reversing point. This turn 
is repeated three times and the occipitofrontalis portion 
of the bandage is repeated three times. 

It is secured by pins placed at the reversing and inter- 
secting points (Fig. 10). 

Uses. — Same as Barton's bandage. 




Fig. 10. — Gibson's bandage. (Fowler's Surgery.) 

Recurrent Bandage (2 inches by 4 yards). — Fix the 
roller by a circular turn from the occiput to the fore- 
head and back again. Continue for two turns. Upon 
reaching the occiput at the end of the second turn the 
bandage is reversed, carried forward, across the top of 
the head to the frontal region, where it is held in place by 
an assistant and reversed backward and forward, first 
on one side and then on the other, overlapping the pre- 
vious turn by f inch until the entire head is covered. 
The bandage is then again reversed and the free ends 
held in place by circular turns around the occipitofrontal 



BANDAGING AND DRESSINGS 7 1 

region and secured by pins at the reversing points (Fig. 

ii). 

Uses. — To retain dressings to the head and scalp and 
to make compression. 

Double Head Recurrent (2 inches by 4 yards) . — Two 
bandages. The ends of the bandages are sewed together. 
Place the portion between the two rollers on the forehead 
and carry the rollers backward until they meet opposite 



Fig. 1 1 . — Recurrent bandage of the head. (Fowler's Surgery.) 

the occipital protuberance. At this point the bandages 
are reversed, one going circularly around the head, the 
other backward and forward over the scalp, each turn 
being caught by the circular bandage, and so on until 
the head is entirely covered. The bandages are then 
continued as circular turns until the bandage is finished. 

Uses. — To retain dressings to the scalp. 

Occipitofrontal Bandage (2 inches by 4 yards). — The 
end of the bandage is placed upon the forehead. To fix 



72 SURGICAL TECHNIC 

it, a circular turn is made around the forehead and the 
occiput. A circular turn is then made so that it reaches 
down as far as possible posteriorly and as far up on the 
forehead as possible. The next turn is made so that the 
posterior portion is above the occiput and the anterior 
portion above the eyebrow. These turns may be re- 
peated as many times as desired (Fig. 12). 

Uses. — To secure dressings on anterior and posterior 
portions of scalp. 




Fig. 12. — Occipitofrontal bandage. 

Liebreich's Eye Bandage.— Strip of flannel, white or 
black, 2\ inches by 8 to 10 inches, fitted with tapes at the 
extremities. Apply to one eye obliquely, reverse the 
tapes by crossing at the occiput with a circular turn, and 
tying. Apply to both eyes transversely with circular turn 
of the tapes and tie (Fig. 13). 

Crossed Bandage of Eye (2 inches by 6 yards). — The 
bandage is fixed by a circular turn from the occiput to 
the forehead. The bandage is then carried from the 



BANDAGING AND DRESSINGS 



73 



occiput below the right ear, up over the outer portion of 
the cheek to the base of the nose, and continued to the 
occiput, passing below the left parietal eminence. These 




Fig. 13. — Modified Liebreich's eye bandage. 

turns are alternated, the one passing below the ear over- 
laps the former turns two-thirds. Continue until the de- 




Fig. 14. — Figure-of-8 of one eye. 



sired result is obtained. Flannel bandage is more com- 
fortable (Fig. 14). 

Uses. — To retain dressings to the eye. 



74 SURGICAL TECHNIC 

Double Crossed Bandage of Both Eyes (2 inches by 
6 yards). — The bandage is fixed by two occipitofrontal 
circular turns. The bandage is then carried forward 
below the ear, crossing the cheek to the root of the nose, 
and back to the occiput. A circular occipitofrontal 
turn is then made, and the bandage carried below the 
right parietal eminence to the root of the nose ; downward 
across the cheek under the left ear, to the occiput. These 
turns are repeated as described above until the desired 
result is obtained (Fig. 15). 

Use. — To hold dressings on both eyes. 




Fig. 15. — Figure-of-8 of both eyes. 

Figure-of-8 of Head and Neck (2 inches by 3 yards).— 
Fix the bandage by two circular turns around the neck, 
starting just below the occiput. Then carry the bandage 
upward above the right ear over the forehead above the 
left ear and back to the starting-point. Alternate these 
turns until the bandage is finished. 

Uses. — To retain dressings to the throat and back of 
the neck. 

Suspensory and Compressor Bandages of the Breast 
(2 J inches by 7 yards). — Place the end of the bandage 



BANDAGING AND DRESSINGS 75 

upon scapula of the injured side. Secure by two oblique 
turns carried over the opposite shoulder and conducted 
downward under the breast and carried to the axilla of 
the same side. Then carry the end of the bandage trans- 
versely around the chest, covering in the lower portion 
of the injured or affected breast. Repeat these turns, the 
oblique turn from the axilla over the shoulder alternating 
with the transverse turns around the chest until the 




Fig. 16. — Bandage for the breast. (Fowler's Surgery.) 

breast is covered in. Each series of turns in ascend- 
ing should obscure two-thirds of the foregoing turn 
(Fig. 16). 

Use. — This bandage is used to hold dressings to the 
breast and make compression on the breast at the same 
time. 

Double Breast Bandage. — The roller is started from 
the scapula of the affected side, and carried over the 
shoulder of the opposite side to the front of the chest, 
thence under the affected breast and obliquely along the 



76 SURGICAL TECHNIC 

lateral and back of chest to its starting-point. This 
turn is repeated in order to secure the end of the bandage. 
The second turn is a circular one around the chest just 
below the breasts. The third turn is started at the point 
of the initial extremity, and the bandage is carried around 
the chest wall to the under surface of the second breast. 
From here it is carried over the front of the chest, thence 
over the opposite shoulder, and back over the chest to the 
starting-point. First, second, and third turns respec- 




Fig. 17. — Double breast bandage. (Fowler's Surgery.) 

tively are now repeated, each turn covering in two-thirds 
of the foregoing turn, and in this way both breasts are 
securely and neatly covered (Fig. 17). 

Use. — Support and pressure of breast. 

Figure-of-8 of Back and Chest (2 \ inches by 7 yards). — 
Place the initial end of the bandage on the back between 
the scapula?. Carry the bandage upward over the right 
shoulder, down under the axilla, and back to the starting- 
point. Continue over the left shoulder to the axilla and 



BANDAGING AND DRESSINGS 



77 



back to the starting-point. Continue these turns until 
the bandage is finished (Figs. 18, 19). 

Uses. — To retain dressings on upper part of back and 
to pull shoulders back. 









Vy - -v 










Hr 


\ 








.,#■, "■: 




i *•■•■ '■ 


1 A 






: i 




Fig. 18. — Posterior figure-of-8 
bandage of the chest. (Fowler's 
Surgery.) 



Fig. 19. — Anterior figure-of-8 
bandage of the chest. (Fowler's 
Surgery.) 



Spica Bandage of the Shoulder (2 \ inches by 7 yards). 
— Fix the bandage by circular turns at the insertion of 
the deltoid. Then carry the bandage across the arm, 
over the anterior portion of the chest to the axilla, and 
across the back to the starting-point, then under the arm 
and repeat as described above, each turn overlapping the 
previous turn two-thirds. Continue thus until the 
shoulder is covered. This bandage may be put on in a 
similar way for the left shoulder, providing one uses the 
left hand (Fig. 20). 

Use. — To retain dressings on shoulder. 



SURGICAL TECHXIC 




Fig. 20. — Ascending spica of the shoulder. (Fowler's Surgery.) 

Velpeau's Bandage. — Two to three rollers, 2 J inches 
by 7 yards each. The hand of the injured side is placed 




Fig. 21. — Velpeau's bandage- 
first turn. (Fowler's Surgerv.) 



Fig. 22. — Velpeau's bandage — 
second turn. (Fowler's Surgery.) 



so that the tips of the fingers touch the sound clavicle. 
The initial end of the bandage is placed over the sound 



BANDAGING AND DRESSINGS 



79 



scapula and the bandage carried over the point of the 
affected shoulder, then backward over the outer surface 
of the arm, behind the elbow, across the chest to the sound 
axilla, and under it to the starting-point. Repeat this 
turn, thence making a circular turn around the chest over 
the top of the injured elbow and back to the starting-point. 
The first turn is repeated, overlapping three-quarters of 
the first turn toward the middle line of the body, then a 
circular turn, then a shoulder turn until the tip of the 




Fig. 23. — Velpeau's bandage completed. (Fowler's Surgery.) 

elbow is reached by the shoulder turns, after which only 
circular turns are made until the arm is encased in the 
bandage. In applying this bandage, as in any other 
bandage where skin surfaces come together, a layer of 
lint or a towel should be placed between the surfaces to 
prevent excoriation (Figs. 21, 22, 23). 

Use. — Fracture of clavicle. 

Descending Spica of Shoulder (2 J inches by 7 yards). — 
The initial end of the roller is placed over the sound scap- 



8o 



SURGICAL TECHNIC 



ula and the bandage carried upward over the injured 
shoulder, downward to the anterior fold, through the 
axilla, then upward and forward over the shoulder, across 
the chest, under the opposite axilla to the starting-point, 
each turn overlapping the preceding turn two-thirds. 
Repeat these turns until the shoulder is covered. 

Use. — To retain dressings on shoulder. 

Desault Bandage (2 inches by 7 yards). — Three to five 
rollers. Oval pad for axilla. 

First Roller. — The arm is elevated with the oval pad 
placed in the axilla. The free end of the bandage is 




Fig. 24. 



-Desault's bandage, first 
roller. 




Fig. 25. — Desault's bandage, 
second roller. 



placed over the pad and held in place by two or three 
circular turns around the chest. Each turn should over- 
lap the preceding one two-thirds of its width. It is then 
brought across the front of the chest, over shoulder, 
under the axilla, and back to the starting-point. 

Second Roller. — The arm is brought down to the side 
of the body with the elbow flexed at a right angle and 
held in place by circular turns around the chest and arm 
until the arm is covered, each turn overlapping the pre- 



BANDAGING AND DRESSINGS 



81 



ceding turn two-thirds. This may be started from above 
downward or the reverse. 

Third Roller. — The free end of the bandage is placed in 
the sound axilla and the bandage carried obliquely across 
the front of the chest, over the injured shoulder, down the 
back of the arm to the elbow, thence upward over the 
forearm to the starting-point. Then upward across the 
back of the chest, over the injured shoulder, down the 
front of the arm, around the elbow obliquely, upward 
across the back to the starting-point. These turns should 




Fig. 26. — Desault's bandage, third roller. 



.be alternated, each turn overlapping the preceding turn 
until three sets have been completed (Figs. 24, 25, 26). 

Uses. — Fracture of clavicle and dislocation of shoulder. 

Jones* Position for Fracture of the Elbow. — This con- 
sists in flexing the forearm upon the arm and by holding 
it in place by a strip of adhesive plaster wound several 
times around the arm and forearm, and the arm supported 
by tying the wrist to the neck by means of a bandage. 

Figure-of-8 Bandage of the Elbow (2 inches by 4 yards) . 
— The bandage should be applied with the elbow flexed. 
The end of the bandage is applied a few inches below the 
6 



82 SURGICAL TECHNIC 

elbow- joint. A few circular turns fixes the bandage. The 
end of the bandage is then carried across the flexure of the 
joint and a circular turn is made a few inches above the 
joint. The bandage is then carried obliquely to the start- 
ing-point and a circular turn is here made. Alternate 
the circular turns below the joint with those above the 
joint, each time obliquely crossing the flexure of the elbow. 
The turns gradually approach the tip of the olecranon 




Fig. 27. — Figure-of-8 bandage of the elbow. (Fowler's Surgery.) 

from both directions and the bandage is completed by a 
circular turn (Fig. 27). 

Uses. — To retain dressings and as part of the spiral 
reversed of the upper extremity. 

Spiral Reversed of the Forearm d\ inches by 7 yards). 
— The end of the bandage is fixed by one or two circular 
turns around the wrist. It is then carried upward by 
two or three spiral turns until the increased circumference 



BANDAGING AND DRESSINGS 



83 



makes reversed turns necessary. These turns are made 
by holding the bandage in place with the thumb of the 
left hand, slightly relaxing the roller held in the right 
hand, and at the same time pronating the right hand. 
The bandage is now continued around the forearm, where 
another reverse is made, and so on until the elbow is 
reached, where the bandage is ended by circular turns. 

Use. — To retain dressings on forearm. 

Spiral Bandage of the Finger (1 inch by i| yards). — 
The bandage is secured by circular turns around the 




Fig. 28. — Spiral bandage of the finger. (Fowler's Surgery.) 

middle phalanx, and carried over the tip of the finger by 
oblique turns. It is then continued, gradually ascending 
the finger by circular turns, each turn overlapping the 
preceding one by two-thirds until the base of the finger 
is reached. It is then passed obliquely across the back 
of the hand to the wrist, where one or two circular turns 
are made. It is then carried to the base of the finger, 
where it is pinned or tied in place (Fig. 28). 
Use. — To retain dressings to fingers. 



84 SURGICAL TECHNIC 

Spiral Reverse of Finger (i inch by ij yards). — The 
end of the bandage is secured by one or two turns of the 
bandage around the phalangeal joint, and the bandage 
carried upward by spiral reversed turns until the base of 
the finger is reached. Finish by circular turns. 

Use. — To hold dressings on fingers. 

Spica Bandage of Thumb (i inch by ij yards). — The 
bandage is fixed by circular turns around the wrist. The 
bandage is then continued over the back of the hand to 
the tip of the thumb, across the tip of the thumb, over 
the back of thumb to the wrist, where a circular turn is 




Fig. 29. — Spica of the thumb. (Fowler's Surgery.) 

made. These turns are repeated, each turn overlapping 
the preceding turn by two-thirds, until the thumb is 
covered (Fig. 29). 

Use. — To retain dressings to the thumb. 
Demigauntlet Dorsal Bandage (1 inch by 4 yards). — 
The bandage is fixed by circular turns at the wrist. It 
is then carried across the back of the hand to the base of 
the first finger, where a circular turn is made and the ban- 
dage is returned to the wrist. Each finger is encircled in 
turn and the bandage is finished by a few figure-of-8 
turns around the wrist and hand (Fig. 30). 

Use. — To hold dressing on back of hand. 



BANDAGING AND DRESSINGS 85 

Demigauntlet Palmar Bandage.— The application is 
the same as the demigauntlet bandage of the dorsal sur- 
face of the hand, with the exception that the turns are 
made across the palmar instead of the dorsal surface of 
the hand. 

Use. — To retain dressings to palmar surface of hand. 




Fig. 30. — Demigauntlet bandage. (Fowler's Surgery.) 

Single Spica of Groin, Ascending (2 J inches by 7 yards). 
— This bandage should be applied with the right hand 
for the right side and with the left hand for the left side. 

The bandage is fixed by circular turns around the abdo- 
men. Upon reaching the anterior superior spine, the 
bandage descends across the groin around the thigh, up 
to the anterior superior spine, where a circular turn is 
made around the abdomen. These turns should be 
alternated, each turn overlapping the preceding turn by 
two-thirds. The bandage is completed by a circular turn 
around the abdomen (Fig. 31). 

Use. — To retain dressings in groin. 



86 



SURGICAL TECHNIC 




Fig. 31. — Ascending spica of the groin. (Fowler's Surgery.) 

Descending Spica of the Groin (2! inches by 7 yards). 
— The descending spica of the groin is applied in the 
same manner as the ascending, with the exception that the 




Fig. 32, — Descending spica of the groin. (Fowler's Surgery.) 



turns descend instead of ascend. It is necessary to have 
the first turn, then, as high as possible (Fig. 32). 
Use. — To retain dressings to the groin. 



BANDAGING AND DRESSINGS 87 

Double Spica Bandage of Groin. — Instead of using the 
complicated double bandage, it is advisable to apply a 
right and left single spica. 

Figure-of-8 of the Knee (2 J inches by 2 yards). — The 
bandage is fixed by circular turns around the upper 
portion of the leg. It is then carried across the popliteal 
space and a circular turn made around the thigh, descend- 
ing across the popliteal space, and by circular turns car- 
ried around the leg. These turns are repeated, each turn 




Fig. 33. — Figure-of-8 of the knee. (Fowler's Surgery.) 

overlapping the preceding turn two-thirds until the 
popliteal space is covered in. The bandage is completed 
by a few circular turns around the thigh (Fig. 33). 

Use. — To retain dressings to popliteal space. 

Recurrent Bandage for a Stump (2 J inches by 6 yards). 
— Fix by circular turns near the lower end of the stump. 
Continue by recurrent turns covering in the end of the 
stump. Complete by ascending oblique spiral or spiral 
reversed turns, each turn overlapping two-thirds of the 
preceding turn (Fig. 34). 



88 SURGICAL TECHXIC 

Figure-of-8 Bandage of Leg. — The end of the bandage 
is fixed by one or two circular turns around the ankle. 
The bandage is then carried upward by spiral turns until 
the diameter of the leg increases, necessitating oblique 
turns. The bandage is then carried up across the leg 
to just below the knee, where a circular turn is made, then 
downward across the anterior surface of the leg. These 
turns are repeated, each turn overlapping the previous 




Fig. 34. — Recurrent bandage of the stump. (Fowler's Surgery.) 

turn two-thirds of its width until the whole leg is neatly 
covered. The bandage is completed by one or two 
circular turns just below the knee. 

Use. — Retaining dressing to leg. 

Spiral Reverse of Lower Extremity (2| inches by 7 
yards). — The bandage is fixed by circular turns around 
the ankle, and then carried upward by spiral turns until 
they no longer lie flat upon the leg. Then, by spiral 



BANDAGING AND DRESSINGS 



8 9 



reversed turns, the bandage is continued up to the knee, 
around the knee by figure-of-8 turns, and continued up 





.— - -~ 






Fig. 35. — Spiral reverse of the lower extremity. (Fowler's Surgery.) 

the thigh by spiral reversed turns. The reversed turns 
are made as in the arm by drawing the bandage taut, 
holding it in place with the left hand, slightly relaxing the 





Fig. 36.— Figure-of-8 of the Fig. 37.— Spica of the foot, 
foot and ankle. (Fowler's Sur- (Fowler's Surgery.) 

gery.) 



bandage, pronating the hand so that the part of the ban- 
dage that was against the skin is now away from it. The 



90 SURGICAL TECHXIC 

bandage is continued around the leg until you reach the 
line of the reverse, where a reverse is again made (Fig. 35). 

Use. — To retain dressings on the lower extremity. 
Spica Bandage of Foot (2 inches by 3 yards). — The 
bandage is fixed by a circular turn around the ankle and 
is then carried across the anterior surface of the foot to 
the base of the toes, thence across the sole of the foot, 
over the anterior surface of the foot, around back to the 
heel. These turns are repeated, each turn overlapping 
the preceding turn by two-thirds until the ankle is covered 
in (Fig. 37). 

Use. — To retain dressings to foot. 





Fig. 38. — Method of covering the Fig. 39. — Figure-of-8 bandage of 
heel. the instep. 

To Cover the Heel (American Method) (Fig. 38). — 
Circular turns (3) about the ankle (to fix) ; descend by 
oblique turn across the back of the foot; circular turn 
at the base of the toes. Continue by covering the foot 
with ascending spiral reversed turns until the instep 
is reached. Cover the heel by circular turns from the 
instep to the heel, alternating with figure-of-8 turns about 
the sides of the heel. Complete by circular turns, as- 
cending the ankle. 



BANDAGING AND DRESSINGS 



91 



Bandage of the Foot Not Covering the Heel {French) 
(Fig. 39). — Circular turns at the ankle (to fix). Ob- 
lique turn across the back of the foot, descending to the 
base of the toes, where a circular turn is made. Cover in 
the foot to the instep with spiral reversed turns (ascend- 
ing). Complete by circular turns about the ankle and 
lower leg. 

Complete Bandage of the Lower Extremity (see Fig. 35). 
— This bandage is used for applying compression to the 
leg to retain dressings. Circular turns at the ankle (to 
fix); oblique turn, descending across the dorsum of the 



Fig. 40. — T-bandage. 

foot, with a circular turn at the base of the toes. Con- 
tinue by covering in the foot and heel. Ascend the leg 
by circular, oblique, spiral, or reversed spiral, covering in 
the calf. Continue by figure-of-8 turns at the knee. 
Complete by ascending spiral or reversed spiral of the 
thigh. 

T-Bandages, Slings, and T-Binders. — Materials. — 
These are best made from heavy unbleached muslin or 
flannel. 

A T-binder should consist of two pieces of material 
about 4 to 6 inches in width. The horizontal portion 



9^ 



SURGICAL TECHXIC 



should be sufficiently long to surround the part to be 
bandaged and the vertical length should be about iS 
inches. The second piece is sewed to the middle of the 
first Fig. 40 . 

Slings are most frequently used to support the fore- 
arm and are usually designated as the handkerchief and 
roller. The handkerchief sling consists of a piece of 
material approximately 1 yard square folded diagon- 
ally. It is preferable to the roller sling. 




Fig. 41. — The Scultetus bandage. 



A roller sling consists of a 3-inch roller bandage which 
is carried around the neck, then under the wrist, and the 
two ends drawn sufficiently tight to give the desired sup- 
port and tied. 

Scuitetus Bandage. — It is most frequently applied to 
the abdomen and is made of a piece of muslin or gauze 
about 16 inches in width and about one and one-half 
times the circumference of the part. In both free ends 
slits are made about 2 inches apart and 6 inches deep. 
It is used to retain dressings that require frequent 
changing. The opposite ends are tied in a bow-knot. 



BANDAGING AND DRESSINGS 93 

ADHESIVE PLASTER 

Adhesive plaster dressings are usually used to fix 
joints, secure splints in fractures, and in strapping ulcers. 

Rubber Adhesive Plaster. — It is a manufactured prod- 
uct consisting of a linen material covered by a composite 
material with caoutchouc as a base. It has the property 
of adhering to whatever material it comes in contact with. 

Zinc Oxid Adhesive Plaster. — This plaster is prepared 
by incorporating rubber adhesive plaster with oxid of 
zinc. It is equally as adhesive as the rubber plaster, and 
possesses the advantage that it is not apt to produce irri- 
tation of the skin. This plaster has largely supplanted 
both the resin and rubber adhesive plaster in surgical 
dressings. 

Resin plaster is made of resin, lead, and wax spread on 
linen material, and when it comes from the manufacturer 
is covered by a thin tissue paper. 

It should always be kept in a cool place, otherwise it 
deteriorates. 

For application it is necessary to remove the tissue 
paper and gently heat. 

Moleskin adhesive plaster consists of spreading a zinc 
oxid material on moleskin or a heavy flannel. It is es- 
pecially useful in abdominal dressings where support is 
necessary, such as a Rose binder. 

Sayre's dressing for fracture of the clavicle requires 
two strips of zinc oxid adhesive plaster 3 inches wide and 
sufficiently long to encircle the chest one and one-half 
times. A piece of linen encircles the injured arm, then 
one end of the strip is circled round the arm with the 
adhesive side toward the chest. The arm is pulled back- 
ward and the adhesive plaster carried across the posterior 



94 



SURGICAL TECE>"IC 



chest under the sound arm and then back to the front 
part of the chest. Now draw the hand of the injured side 
forward until it touches the sound clavicle. The remaining 
strip is placed on the back over the injured arm and carried 
downward over the tip of the elbow of the injured side, 
up over the back of the hand, over the sound shoulder to 
the starting-point. It is well to cut a hole in the center 
of the adhesive where it crosses the elbow .Figs. 42. .in- 





terior view. ■ -'. . i - Ege r - 



rior view Keen's Surgery.) 



Chest Strapping. — This consists of strips which are cut 
in widths of 2§ inches and sufficiently long to reach from 
1 inch beyond the spine of the vertebra to 1 inch beyond 
the sternum. With the patient sitting, the arm of the 
injured side is held up and the patient is told to exhale, 
at which time the straps are applied one after the other 
from below upward, each strip overlapping the other 
one-third (Fig. 4- 



BANDAGING AND DRESSINGS 



95 



Pelvic Binder. — This consists of a strip of moleskin 
adhesive plaster sufficiently long to pass one and one- 
half times around the hips. One end of the adhesive is 
placed just above the trochanter of the injured side, car- 
ried across the back over the crests of the ilium and 
back to the starting-point, and continued in this line 
until all the strip is in place. 




Fig. 44. — Strapping the ribs (after A. S. Morrow). 



Figure-of-8 of the Knee. — This is well illustrated in the 
accompanying diagram. Strips should be 1 inch wide 
and 11 to 15 inches long (see Fig. 33). 

Strapping of Ulcers of the Leg. — Ulcer of the leg may 
be strapped in the circular or oblique method as is shown 
in the diagram (Fig. 45). 

Strapping of the Joints. — This requires strips of zinc 
oxid adhesive plaster 2 inches wide and sufficiently long 
to extend two-thirds around the joint. The first strap 
is applied a few inches below the joint and the strapping 



9 6 



SURGICAL TECHNIC 



continued until the joint is covered. Each strap should 
overlap the preceding strap by two-thirds. 

This dressing will be found to be satisfactory in the 
treatment of sprains of joints, etc. 

Strapping of the Ankle-joint. — Straps of zinc oxid 
adhesive, ij by 18 inches, are required. The first strap 
is started at a point midway between the knee and the 




Fig. 45. — Strapping an ulcer of the leg. (Keen's Surgery.) 



ankle, applied to the edge of the tendo achilles, carried 
across the sole of the foot and up the opposite side of the 
leg. A strap is next placed so that its middle crosses 
the point of the heel, the ends being carried forward on 
the inner and outer surface of the foot. These straps 
should be alternated until the ankle-joint is covered in. 
One should avoid having these straps meet in the front 
of the foot or make circular constriction (Fig. 46), 



BANDAGING AND DRESSINGS 97 

Buck's extension is a method of obtaining traction 
upon the leg and thigh. The attachment is made by 




Fig. 46. — Strapping the ankle-joint. (Keen's Surgery.) 

adhesive plaster and consists of straps 4J inches wide 
and long enough to reach from well above the knee to 



Fig. 47. — Fracture of the thigh. Completed apparatus and, in addi- 
tion, a long outside T-splint, straps, and swathe. Weights applied. 
(Scudder.) 

loosely around the sole of the foot and up the opposite 
side of the leg to a point opposite the starting-point. 
A piece of wood, 5 by 3 inches, is then placed in the center 
7 



98 SURGICAL TECHNIC 

of the strap. A hole is cut in the center of the board 
through which a rope is passed. The adhesive surfaces 
of the plaster are placed on either side of the leg and thigh 
and are held in place by figure-of-8 turns of adhesive fol- 
lowed by a muslin bandage. 

The extension may be obtained by elevating the foot 
of the bed and tying the rope thereto, or by passing the 
rope over a pulley and attaching weights (Fig. 47). 

Montgomery Straps. — They consist of a strip of zinc 
oxid adhesive from 1 to 2 inches in width and from 3 to 6 
inches in length. The corners of one end of the adhesive 
are turned in and this end punctured. A strip of tape 
is sewed or tied to this. These are placed to either side 
of the wound and tied over the dressing. 
Use. — To hold dressings in place. 

Catheter straps are similar to the above, but are nar- 
rower and shorter. 

PLASTER-OF-PARIS 

Plaster-of- Paris bandages, like all other bandages, are 
made in various lengths and widths. 

This bandage consists of unwashed crinoline or gauze 
with the mesh filled with the best dental plaster-of- Paris. 

The material may be cut in the desired width or length, 
or the whole width of the material may be rolled at once. 
If not used at once, they should be kept in covered metal 
boxes to keep out the dampness. 

Plaster bandages can be purchased at any good apoth- 
ecary shop. 

Application of Plaster-of-Paris Bandage. — The part 
should first be covered by a flannel roller or a bandage 
made of raw cotton and held in place by a gauze bandage. 



BANDAGING AND DRESSINGS 99 

In applying body casts, a union suit of heavy material 
is advisable. 

The plaster bandage should be immersed in water until 
the bubbles cease to escape, the excess water squeezed 
out, and the bandage applied by circular turns. Reverses 
in the bandage are allowable, but not advisable. After 
the application of each bandage, plaster of the consist- 
ency of thick cream should be rubbed in, as in this way less 
bandage will be required. In applying casts to the leg 
three to five bandages are usually sufficient. Strips of 
tin, zinc, or binder's board may be placed between the 
layers of the bandage to increase the tensile strength. 

Plaster bandages set better on dry days. 

Heavy rubber gloves are desirable to keep the hands of 
the operator free from plaster, or if they are not used, 
sugar and glycerin will assist in removing the plaster. 

After the bandages are applied, great care should be 
used so that none of the plaster gets into the plumbing, 
as it will close the drain. 

Removal of Cast. — This is best done with a heavy knife, 
cutting obliquely to the plaster. Vinegar, peroxid of 
hydrogen, etc., are useful to soften the plaster and assist 
in its removal. 

Windows or fenestrations may be cut in the cast. 

After the cast is dry it is well to confine the free ends 
in adhesive to prevent rubbing. 

SPLINTS 

Splints, padded with cotton-batting, oakum, wool, 
or hair, may be constructed from white pine, poplar, 
or willow wood, i to | inch (3-12 mm.) in thickness, 
cut to measured length and width; they may be of 



IOO SURGICAL TECHXIC 

pa5teboard or binder's board, molded to shape by 
soaking in boiling water, or of rawhide similarly worked; 
of felt; plaster-of- Paris: starch (dissolved in cold water, 
after which boiling water is added until the proper con- 
sistence is secured- requires from twelve to forty-eight 
hours to dry- thoroughly (Fig. 48) ; gum and chalk (equal 
parts of gum arabic and precipitated chalk, add sufficient 
boiling water, stirring to obtain a proper consistence of 
solution) applied upon bandages; hatter's felt or binder's 




Fig. 48. — Splint made from plaster-of-Paris bandage. Complete by 
molding to the part: trim after setting has taken place. 

board may be softened in hot water and molded to the 
injured parts. The coaptation splint consists of thin and 
narrow board strips (of bass wood or pine) placed in 
position (side by side, with a slight interval) upon a sheet 
of adhesive plaster, or they may be quilted between two 
pieces of sheeting. The splint is held in position by- 
bandaging or by adhesive straps, and may be employed 
in emergency or to reinforce the ordinary board or 
bracket splint. Fracture-box consists of a stout board 6 
to 8 inches (15-20 cm.) wide by 18 to 30 inches (45-75 cm.) 



BANDAGING AND DRESSINGS IOI 

long, with hinged sides, a foot-board, upright, firmly 
attached at right angles to the bottom board, padded with 
a pillow, cotton-batting, or bran; may be used in treat- 
ing fractures of the lower leg and knee. Bags made from 
stout muslin or light duck canvas cut 14 inches (35 cm.) 
wide by 3 feet (90 cm.) to 5 feet (1.5 m.) long, doubled, 
sewed, and inverted before filling with sand or bran, 
closed with a draw-string or by stitching, are employed in 
fractures of the leg and thigh. Compresses to prevent 
displacement may be made of cotton, lint (folded), 
oakum, and held in place by adhesive straps, bandage, 
or placed upon splints when padding. 

Prevent infection of the soft parts from maceration 
of the skin surfaces after fracture by a thorough cleans- 
ing of the parts before applying the first permanent 
dressing and by "alcohol rubs" at each subsequent dress- 
ing. Neuralgic pain in the region after fracture is due to 
organized blood-clot or exudate. Treat by massage. 
Swelling, loosening, infection, malposition of the parts 
will demand an examination or change of dressings and 
correction by the surgeon. 



CHAPTER VI 

CARE OF OPERATING-ROOM; METHODS OF 
STERILIZATION; CARE OF INSTRUMENTS 

In almost all large hospitals there are three operat- 
ing-rooms, one for general surgical, one for gynecologic, 
and one for septic operations. This is ideal, but unneces- 
sary if correct methods of sterilization are employed. 




Fig. 49. — Kny-Scheerer instrument cabinet, having adjustable shelves 
and a plate-glass partition in the center, which practically divides it into 
two closets. 



Dressing-rooms on each floor are very desirable, 
for besides having everything at hand with which to 



CARE OF OPERATING-ROOM 



I03 




Fig. 50. — Wheeled stretcher. 




Fig. 51. — House stretcher. 



do a dressing properly, the nurse in charge of the patient 
has the opportunity to return and make up the bed 
afresh during the patient's absence. Stretchers are 



104 



SURGICAL TECHXIC 




Fig. 5 : —Improved model sterilizer. 

used to convey patients to and from the operating- and 
dressing-rooms. The wheels generally have rubber 
tires, the top-board is detachable and has four handles. 



CARE OF OPERATING-ROOM I05 

two at each end. At least two stretchers are necessary 
on each floor. 

The material used in the construction and furnish- 
ing of an operating- and dressing-room should be of 
marble, metal, porcelain, and glass, all of which can 
readily be made aseptic. The water-faucets should 
be controlled by automatic foot- or elbow- valves, so 
as to avoid contamination by turning on the spigots 
with the hands after they have been rendered aseptic. 

The operating-room should be kept clean, and should 
be damp-swept and wiped every day; in short, it should 
be in such a condition as to be ready for an operation 




Fig. 53. — Sterilizing tube for edged instruments. 

at a few moments' notice. The supplies for dressings 
should not be allowed to run down, and the instruments 
should always be in a first-class condition. An emer- 
gency bundle, containing everything necessary for an 
emergency operation, should be kept in readiness. 

Sterilization may be either dry or moist; moist heat 
is preferable, because it is more thorough and more 
penetrating than dry heat. For dry sterilization the 
towels and dressings may be placed in covered tin 
pans in an oven the temperature in which ranges 
from 160 to 21 2° F. This method is only used 
in an emergency. For moist or steam sterilization a 
Kellogg, a Sprague, or an Arnold steam sterilizer is 



io6 



SURGICAL TECHNIC 



used. The heat must be continued for fully one hour 
before the operation. 

Regarding the sterilization of instruments surgeons 
differ; some prefer to have their instruments wrapped 
in a towel and put into the sterilizer and allowed to boil 
for fifteen minutes in a I per cent, solution of carbonate 
of sodium to prevent their rusting. All edged instru- 
ments to be boiled in the soda solution should be wrapped 





Fig. 54. — Arnold sterilizer. 



Fig. 55. — Formalin lamp. 



in cotton and packed so firmly that they will not be 
tossed against one another by the solution as it becomes 
agitated in boiling. This agitation seems to be one of the 
reasons why they lose their edge. In a private house a 
tray or basin deep enough to allow the instruments being 
covered by the water are placed on a stove and boiled for 
fifteen minutes. Many operators prefer to have their 
edged instruments and needles placed in a dish contain- 
ing 95 per cent, alcohol for half an hour; then just before 



CARE OF OPERATING-ROOM 



I07 



. 






9 

: 




the operation they are taken out and rinsed with sterilized 
water. Usually the knives are placed in the last three 
minutes of the boiling time. 



108 SURGICAL TECHXIC 

After sterilization the instruments are transferred to 
the instrument-table or to shallow porcelain trays, in 




Fig. 57. — The Rochester sterilizer for instruments and dressings. De 

Lee.) 

which they lie covered with sterilized towels until re- 
quired. 




Fie. 58. — The Rochester sterilizer open. (De Lee.) 

After the operation the instruments should be taken 
apart, washed in cold water to remove all blood, pus. 
and tissue particles, and then thoroughly scrubbed with 



CARE OF OPERATING-ROOM 



IO9 



green soap. Instruments with permanent joints, which 
fortunately are seldom seen now, must receive special 
attention, since it is difficult to get them surgically clean. 
After being scrubbed the instruments are rinsed in hot 
sterilized water, wiped dry with a soft towel, locks oiled, 
and then laid away in the case. The knife-blades must 
be rolled in cotton. The important points to be re- 




Fig. 59. — Latest form of complete sterilizing outfit for dressings, water, in- 
struments, sheets, towels and operating gowns, basins and trays. 



membered in cleaning instruments after the operation 
are: 

First, all instruments that can be so dealt with must 
be taken apart and the rough catches thoroughly cleansed 
in cold water. 

Second, they must be dried carefully in order to 
prevent rusting; for instruments once rusted seem 
always to have a tendency to return to that condition. 



no 



SURGICAL TECHNIC 




Instrument trays are made of porcelain or agate-ware. 

Instrument trays, pitchers, etc., are best sterilized in 

a large steam sterilizer built especially for this purpose. 



CARE OF OPERATING-ROOM III 

They should be allowed to remain in the sterilizer until 
used. Special sterilizers come for the disinfecting of 
bed-pans, douche-pans, etc. They are placed in a 
sterilizer containing the soiled contents with the lid of 
the sterilizer dropped in place and are then sterilized by 
steam. Later, by turning a spigot, the contents are 




Fig. 61. — Sterilizer for the disinfecting of bed-pans, douche-pans, etc. 
(Courtesy of Bernstein Manufacturing Co.) 

drained off and the receptacles are ready for use. All 
hospitals should be equipped with this apparatus. 

Every operating-room nurse should be familiar with 
the names of the instruments necessary for each different 
operation, so as to be able to lay them out when occasion 
requires. Many nurses get together after school hours 
and "make believe" an operation is to take place. 
Each nurse has her duty assigned to her, and each tries 



112 SURGICAL' TECHXIC 

to fulfil it in a thoroughly professional, dignified, and quiet 
manner. Practice of this kind is never lost. 

In the operating-room should be kept two large ledgers, 



Fig. 62. — Glass tray. 

in one of which the house-surgeons, after making the 
morning rounds with the visiting surgeons, should record 




Fig. 63. — Pus basin. 

the number of operations to be performed the next day, 
the time, name of operator, etc. The operating-room 
nurse is thus made acquainted, by consulting the book, 




Fig. 64. — Glass trays. 

of the amount of work before her for the next day, and the 
character of the operations for which she has to prepare. 
On the morning of the operations she makes out a 
list of the floor and number of private room or letter 
of ward and number of bed from which the patients 
are to be brought to the operating-room, and the order 



CARE OF OPERATING-ROOM 



113 



in which the operator wishes them. This list is given 
to the male attendant, who brings up the patients in 
succession, in such a way that while one patient is 
being operated on the next is being anesthetized. The 
head nurse in the operating-room has two or three 
sets of instruments, and during one operation an as- 
sistant nurse is sterilizing the instruments and making 




Fig. 65.— Metal tray. 

preparations for the next operation. There is then 
no waiting on the part of the operator, for as the patient 
operated on is wheeled out of the operating-room the 
next patient is wheeled in. The following chart will 
give an idea as to the way the book is made out and the 
order in which the operations are written. The emer- 
gency operations, accidents, etc., are also recorded, but 
.after the performance of the operation. 



Date. 


Operation. 


Floor. 1 


Time. 


Operator. 


Room 


Ward. 


t5 


Floor. 


Mar 11. 


Laparotomy. 


4 th 


8 A.M. 

8.30 " 


Dr. Murphy. 


19 






sd 




Vaginal hysterec- 






21 








" 


tomy. 
Cholecystostomy. 
Appendicectomy. 


<< 


9.00 " 
0-30 " 
10.00 " 


Johnson. 
" Fenger. 
Morgan. 


24 
16 


B 


TO 


" 


" 


Amputation, breast. 


" 


10.45 " 
11.30 " 


" Kindig. 
" Carter. 




D 
D 


6 
9 




'< 


Appendicectomy. 
Cesarean section. 
Appendicectomy. 


3d 


2 P.M. 

3-oo " 
4.00 " 
6.30 " 


" ' Andrews. 
" Fenger. 
" Eyster. 
" Comegys. 


24 
21 
21 
29 




4th 

2d 

4 th 

2d 



1 Clean operating-room, fourth floor; septic, third floor 
8 



ii4 



SURGICAL TECHNIC 



The second book gives the date on which the patient 
was prepared for operation, by whom prepared, etc., 
as, for example — 



p^SSL ! *«•-»"» 


Antiseptic 
used. 


Operator. 


Floor. 


Room. 


March 10. 


E. A. S. 


Corros. sub. 


Dr. Eyster. 


Fourth. 


No. 21. 


Date of 
Operation. 


Hour. 


Sutures 
used. 


Length of 
time prepared. 


Stitches 
removed. 


Condition . 


March n. 


4 P. M. 


Silkworm- 
gut. 


Two hours' 
boiling. 


March 19. 


Aseptic. 



A book should also be kept in each dressing-room 
showing the number of cases dressed each day, the 
dressing used, and progress since the last dressing. 
It should be kept for the convenience of the dressing- 
room nurse in making an estimate of dressings for the 
next day, and for the convenience of the surgeon in 
knowing what patients are dressed, their condition, 
and in knowing when they are to be again dressed. 
It will also recall condition of last dressing. 



CARE OF OPERATING-ROOM 



115 



Room or, j^- • 

w.rH Diagnosis. 



Ward. 



No. 20, Appendicitis. 
ad floor. 



Operated. 



March 11. 



Operator. 



Dr. Come- 

gys. 



Dressed. 



March 17. 



Died or 
Discharged. 



Discharged 
April 2. 



Remarks. 



CHAPTER VII 

INSTRUMENTS NECESSARY IN DIFFERENT 
OPERATIONS, KEEPING OF CHARTS, SUR- 
GEON'S KIT, ETC 

In many hospitals, small ones especially, where there 
are no medical students or house doctor, the nurse has 
more responsibility than in larger institutions, and 
becomes closely familiar with such details as taking the 
history of the patient; the arranging and sterilization 
of instruments; assisting the operator, giving the anes- 
thetic, and writing out the report of the operation. The 
following charts will be of use in keeping the important 
features of this line of duty in mind. When taking the 
patient's history it is a good plan to allow her to describe 
her condition in her own words. Any peculiarities of the 
patient's manner and other points which may be observed 
can be noted, and afterward the questions necessary for 
making out the charts may be asked. 

Family History. 

Age. Health. Disease. Cause of death if dead. 
Father. 
Mother. 

Brothers (number). 
Sisters (number). 
Wife or husband. 
Children (number). 

Uncles or aunts with epilepsy, insanity, tuber- 
culosis, or cancer. 
116 



INSTRUMENTS 117 

Personal History. 

When born. Where lived. Peculiarities of cli- 
mate. Occupations. Habits (as to eating, 
drinking, sleeping, etc.). Appetite. Condition 
of bowels. Nervousness. 
(When Female.) 

Sexual History. 

I. Menstruation: 

(a) First at what age. 

(b) Regularity. No. days. 

(c) Duration. No. days. 

(d) Amount. 

Color. 

(e) Character of discharge i Consistency. 

[Odor. 

(/) Intermenstrual discharge. 

(g) Dysmenorrhea — when. 

TT _. . (Number. 

11. Fregnancies -j . . 

(Sickness or peculiarities. 

Number. 

III. Miscarriages { Sickness. 

^ Fever. 

IV. Labors: 

(a) Number. 

f Easy. 

/, V ru * J Difficult. 
(0) Character <( „ 

I Spontaneous. 

1 • 

t Instrumental. 

(c) Peculiarities. 

id) Sickness postpartum, if any. 



Il8 SURGICAL TECHNIC 

Previous Illness. 

Starting with childhood, give different sicknesses 
and age at which same occurred, following life 
of patient to present time simply with reference 
to sickness, including appetite, bowels, urine, 
headaches, pains, coughs. 

Present Sickness. 

Date. 

^ ^, (Chills, pains, locations, se- 

Onset. Character. 1 . . . 

[ verity, etc. Peculiarities. 

Progress and changes to present time. 

Changes. Appetite. Bowels. Urine, etc. 

Examination. 

Surgeon's Kit. — The packing of a surgeon's bag is often 
done by the operating-room nurse. Many surgeons use 
the telescope valise, or kit, as it is more commonly called; 
while others employ a regular surgeon's bag. Before 
the bag is packed the nurse makes out the list of neces- 
sary articles, and as each article is put in it is checked 
off the list. When packed, a copy of the list is securely 
pinned upon a towel inside, where the surgeon can see it 
on first opening the bag. The kit is packed by first lay- 
ing in two large sterilized towels, the ends of which hang 
over the edges of the bag. Together with the instru- 
ments, which are placed in a linen instrument-roll, and 
the dressings the kit should contain three new nail- 
brushes, soap, razor, hypodermic syringes with tablets 
of strychnin sulphate (gr. -^), atropin sulphate (gr. y^), 
and morphin sulphate (gr. J), cocain hydrochlorate (gr. 
|), sterile camphorated oil, ether, and chloroform (with 



INSTRUMENTS 



119 



cone and mask), alcohol (95 per cent.) 1 pint, tincture of 
iodin (5 per cent.), tablets of corrosive sublimate and 
sodium chlorid, iodoform gauze, plain gauze, gauze 
sponges, white suits, caps, and canvas shoes for the 



MMmmmm 




mmmummm 



Fig. 66. — Canton-flannel roll for instruments. 

operator and assistants, Kelly pad, rubber gloves, 
safety-pins, absorbent cotton, twelve towels, a rubber 
apron, ligatures, sutures, and rubber and glass drainage- 
tubes. The glassware should be packed in the middle, 




Fig. 67. — Instruments wrapped in canton-flannel roll. 

to prevent breakage. When the kit is packed a third 
towel is laid over the contents, the edges of the other two 
are brought up, and all pinned together with safety-pins. 
The instrument-rolls are very serviceable in econo- 
mizing space and in keeping the instruments aseptic. 



120 SURGICAL TECHNIC 

OPERATION BLANK 



Service of Dr. . . 

Date. March 10, igi6. 

Name 



j 
I. PREPARATION OF PATIENT FOR OPERATION. 

II. ANESTHETIC. ANESTHETIST. 
Temperature. 

Before operation. 
After operation. 
Pulse and Respirations. — To be taken continuously during 
operation. 

III. PREPARATION OF FIELD OF OPERATION. 

IV. POSITION OF PATIENT DURING OPERATION: 
V. PRIMARY MANIPULATIONS. 

VI. INCISION AND HISTORY OF OPERATION. 
VII. TREATMENT OF WOUND. 
VIII. DRAINAGE. 
IX. CLOSURE OF WOUND. 
X. DRESSING. 

XI. RECOVERY FROM ANESTHETIC. 
XII. AFTER-TREATMENT. 



INSTRUMENTS 



121 







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CD 


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*5 OD 
o 


§ 8 i 




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o 


1 




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1 




1 


i S 

o c 




So 

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5 § 




3 




i 


1 1 


3 * 


3 C 


1 * 


i i 


2 I 




! = 


O ( 


> 

3 









122 SURGICAL TECHNIC 

They are made of linen, canton flannel, or toweling, 
i yard long; and through the middle of each are adjustable 
loops in which the instruments are placed. When soiled 
the rolls may be washed and sterilized. 

Needles of various shapes and sizes required for 
an operation are sterilized with the instruments. Many 
operators prefer the needles to be threaded, then at- 
tached to a towel, which is folded, enveloped in another 
towel, and securely fastened. These bundles are dry ster- 
ilized and are not opened until called for by the operator 
or his assistants. After the operation is completed the 
sutures and ligaments which have not been used are care- 
fully dried and resterilized. In choosing the needles care 
must be taken that only sharp needles and strong sutures 
and ligaments are selected for use. 

INSTRUMENT LIST 

The following is a list of instruments generally used. 
Each operator will require additional instruments. The 
operating-room nurse should make out a list of the addi- 
tional instruments each operator requires: 





Simple Dressing Tray 


Forceps, i pair. 
Groove director. 


Scissors, i pair 
Probe. 

Head Operations 


Hemostats, 2 pairs. 
Glass syringe. 




Trephining, Brain Tumors 


, Etc. 


Knives. 
Tourniquet. 
Gigli's wire saw. 
Dural separator. 
Retractors, toothed 
\rc lie-holder. 
Scissors. 


Trephines. 

Cranial rongeur for- 
ceps. 
Periosteal elevator. 
Electrodes. 
Fine dural needles. 


Hemostats. 
Chisel. 
Mallet. 

Dural separator. 
Forceps. 

Head mirror or head 
light. 



INSTRUMENTS 



123 




Fig. 69.— Hudson's cranial rongeur forceps. 




Fig 70 —Lentz's cranial chain tourniquet. 




Fig 7I — Gigli wire saw and handle. 



124 



SURGICAL TECHNIC 




Fig. 72. — Hudson's cranial trephine, burs and brace. 

Spinal Puncture 
Glass or Record syringe and spinal needle. 



Laminectomy 

Knives, 2. Scissors, 3 pairs. 

Periosteal elevator Needles. 

Forceps, 2 pairs. Chisels. 

Forceps, bone-cutting, Retractors. 
2 pairs. 



Rongeur forceps, 2 pairs. 
Needle-holder. 
Mallet. 
Gigli saw. 



INSTRUMENTS 



125 



Knives. 
Forceps. 

Retractors, self-retain- 
ing. 
Curets, four sizes. 
Syringe. 
Mallet. 



Ear Operations 
Mastoid 

Scissors. 
Needle-holder. 
Head mirror or head 

light 
Chisels, Alexander's. 
Rongeur forceps. 



Probe. 

Guard for facial nerve. 

Hemostats. 

Needles. 

Periosteal elevator. 

Ear speculum. 

Groove director. 



Nose and Throat Operations 
Cleft Palate 



Knives. 

Forceps, rat-toothed. 

Forceps, plain. 

Forceps, swab. 

Retractor. 



Scissors. 
Head mirror. 
Fine needles. 
Mouth-gag, 
taining. 



self-re- 



Hemostats, 12. 
Periosteal elevator. 
Needle-holder. 



Knives. 
Mouth-gag. 
Hemostat, tonsil. 
Hemostats. 



Tonsillectomy 

Snare, Beck-Schenk. 
Scissors. 
Head mirror. 
Tonsil punch. 



Tonsillotome. 
Tongue depressor. 
Forceps, tonsil-holding. 
Sponge-holders. 



Adenectomy 
Instruments necessary for Tonsillectomy and the following: 

Adenoid curet. Nasal dilator. Postnasal cutting 

Rubber ear syringe. Cotton-holding for- ceps. 
ceps. 



for- 



Adenotome. 



Knives. 

Retractors. 

Scissors. 



Tracheotomy 

Needle-holder. 
Hemostats, 12. 
Sharp hooks, 2. 



Tracheotomy tube. 
Trachea cannula. 
Forceps, 2 pairs. 



126 



SURGICAL TECHNIC 





Fig. 73. — Buck's mastoid curet Fig. 74. — Allport's mastoid re- 
(four sizes). tractor (self-retaining). 




Fig. 75. — Langenbeck's periosteal elevator 




Fig. 76. — Stacke's guard for facial nerve. 




Fig. 77. — Hartmann's round tonsil punch. 



INSTRUMENTS 



127 



(H) 



\ . 




Fig. 79. — Sinexon's nasal 
dilator. 




Fig. 78.— Tonsil snare. 



Fig. 80. — Luer's trachea cannula. 



128 



SURGICAL TECHNIC 




Lj 



Fig. 81.— DeRoalde's Fig. 82.— Richards' Fig. 83.— Ermold's ton- 
adenoid curet. tonsil-holding forceps. sillotome. 



Submucous Resection. 

Applicators. Nasal specula, Bal- Knives. 

Scissors. linger. Septum elevator. 

Septum punch. Head mirror. Ballinger's swivel knife. 

Nasal specula, Killian. Nasal tampons. 



Knives. 
Hayes' saw. 
Hemostats. 
Scissors. 



INSTRUMENTS 

Tongue, Removal of 

Tongue forceps. 

Needles. 

Forceps, rat-toothed. 

Forceps, plain. 



129 



Forceps, bone-cutting. 

Needle-holder. 

Mouth-gag. 



Glands of Neck, Removal of 

Knives. Forceps, plain and Mayo dissecting scissors. 

Retractors. toothed. Hemostats. 

Needle-holder. Needles. Crile clamp. 

Scissors. Aneurysm needle. 

Goiter 
Same instruments as for Removal of Glands of Neck with these added: 

Goiter forceps. Goiter compressing Kocher director, 

forceps. 

Ligation of Arteries, Carotid 
Same instruments as for Removal of Glands of Neck. 



Eye speculum. 
Cataract knife. 
Iris spatula. 



Eyes 

Iridectomy 

Iris scissors. Iridectomy knife. 

Iris forceps, straight Lid retractor, 
and curved. 



Cataract Extraction 

The same instruments as are required for Iridectomy and the following 
in addition: 



Cystotome. 



Lens tractor. 



Lens scoop. 



Removal of Eye and Tenotomy 

Self-retaining lid re- Strabismus hooks, Scissors. 

tractor. small and large. Small curved needles. 

Forceps, toothed. Hemostats. Needle-holder. 

9 



130 



SURGICAL TECHNIC 




Fig. 84.— Fox's eye specu- Fig. 85— Des- Fig. 86.— Fig. 87.— Iris 
l um . marre's lid re- Iris spatula. knife, 

tractor. 




Fig. 88.— Iris forceps. 




Fig. 89.— Iris scissors; a, Wecker's. 



INSTRUMENTS 



131 



Aspirating set. 
Knives. 

Hemostat forceps, 
plain and toothed. 



Knives. 

Grooved director. 
Retractors 



Chest Operations 
Empyema 

Scissors. Drainage-tubes. 

Periosteal elevator. Needles. 

Bone-cutting forceps. Needle-holder. 

Amputation of Breast 

Scissors. Needles. 

Forceps, toothed and Hemostats. 

plain. Needle-holder. 



Abdominal Operations 
Abdominal Section 
Usual instruments for any abdominal section, to which will be added 
instruments required for any special abdominal operation. 
Knives. Scissors. Forceps, toothed and 

Hemostats. Clamps, Kocher or plain. 

Aneurysm needle. Kelly. Retractors, abdominal. 

Intestinal clamps, Needles. Needle-holder. 

medium. Allis' forceps. 



Herniotomy 
Same instruments as are required in above operation and small re- 
tractors. 

Stomach Operations 
Same instruments as for Abdominal Section and the following addi- 
tions : 



Stomach clamps. 



Murphy button. 



Intestinal Operations 
Resection 
Same as Abdominal Section. 



Gall-bladder and Liver Operations 
Same as for Abdominal Section with the following additions: 
Gall-duct probes. Gall-stone scoops. Special drainage-tubes. 

Trocar. 



132 



SURGICAL TECHNIC 






M 




^ — ^ abed 

Fig. 90. — Mayo's operating knife Fig. 91. — Amputating knives: a, 
or scalpel. Catling's medium; 6, Liston's small; 

c, Catling's long; d, Liston's long. 



INSTRUMENTS 



133 







Fig. 92— Mayo's oper- Fig. 93.— Curved Fig. 94.— Emmet's an- 
ating scissors. scissors. gular bent scissors. 




Fig. 95. — Dressing forceps. 




Fig. 96. — I. S. Stone's tissue forceps. 



SURGICAL TECHNIC 



Fig. 97. — Segond's volsella forceps. 




Fig. 98. — Tait's hemostat for- 
ceps. 





Figs. 99-101. — Kelly's curved 
round needles. 



Fig. 102. — Noble's 
improved Reiner's 
needle-holder. 



INSTRUMENTS 



135 



Operations Upon the Uterus 
Hysterectomy, Suspension, Etc. 
Same instruments as for Abdominal Section and the following: 
Hysterectomy clamps. Forceps, large. 



Dilation and Curetment 



Specula, self-retaining. 
Specula, Sims'. 
Irrigator, uterine. 
Sound, uterine. 
Curets, dull and sharp. 
Curet, Martin's. 



Curet, irrigating. 
Tenaculum , single and 

double. 
Dilators, Goodell, large 

and small. 
Dilators, Hegar's. 
Dilators, Metranoikter. 



Forceps, uterine. 

" dressing. 

" tenaculum. 

" placental. 
Scissors. 
Norris or Wiley drain. 



Perineorrhaphy and Repair of Cervix 
Same as above and — 
Hemostats. Needle and needle- Tenacula. 

Knives. holder. Emmet scissors. 

Scissors. Hooks. Shot forceps. 



Knives. 
Scissors. 
Kidney clamp. 
Needle-holder. 



Kidney Operations 
Forceps. 

Retractors, large. 
Ureteral probe. 
Ureteral catheter. 



Hemostats. 

Kidney elevator forceps. 

Needles. 



Operations Upon Extremities 
A mputations 

Martin's rubber ban- Saws. 

dage. Periosteal elevator. 

Tourniquet. Retractors, metal. 

Hemostats. Retractors, muslin, two 
Knives. or three-tailed. 



Scissors. 



Amputating knives. 



Forceps, lion-jaw. 
" sequestrum. 
" rongeur. 
" bone-cutting. 
" plain. 

rat-toothed. 



Resection 
Same and the following additions. 
Mallet. 



Chisel. 



136 



SURGICAL TECHNIC 




Fig. 103. — Linnartz's stomach clamp forceps. 




Fig. 104. — Deschamp's aneurysm needle. 





Fig. 105. — Murphy button. 




Fig. 106. — Mayo-Simpson's self -retaining 
retractor. 



INSTRUMENTS 



137 




Fig. 107. — Volkmann's retractor. 




iliill * 





Fig. 108. — Retractors: a, Collin's; b, Kelly's. 




Fig. 109. — Potain's aspirator. 



138 



SURGICAL TECHNIC 




Fig. no. — Sims' speculum. 




Fig. in. — Auvard's self-retaining specu- Fig. 112. — Curets: A, Thomas' 
lum. dull; B, Sims' sharp 




Fig. 113. — Hoffman's uterine irrigator. 



INSTRUMENTS 



139 



Bone-plating and Osteoplastic Grafting 



Tourniquet. 
Scissors. 
Chisels. 
Retractors, toothed 

and plain. 
Nails. 
Curets. 
Knives. 



Hemostats. 
Saws. 

Bone-plates. 
Electric engine and 

saws. 
Needles. 
Towman bone-holding 

clamp. 



Forceps. 

Grooved director. 

Drills. 

Screws. 

Screw-driver. 

Gouges. 

Needle-holder. 



Knives. 
Forceps. 
Needle-holder. 
Scissors. 



Operations Upon Male Genital Organs 
Suprapubic Cystotomy 
Retractors, toothed Needles. 

and plain. Hemostats. 

Sounds. Drainage-tubes. 



Suprapubic Prostatectomy 
Same as foregoing, with — 

Hemostats. Double tenaculum. 



Perineal Prostatectomy 
Same as Suprapubic Cystotomy and — 



Guide. 
Lobe forceps. 



Catheters. 
Syringe. 



Young's tractor. 
Retractors. 

Litholapaxy 
Lithotrite. 
Cystoscope. 



Catheters. 



Stone-searcher. 



Internal and External Urethrotomy. 



Sounds, urethral. 
Urethrotomes, dilat- 
ing. 
Hemostats. 
Retractors. 



Catheters, filiform. 
Catheters, Gouley. 
Knives. 
Scissors. 
Grooved director. 



Guide. 
Forceps. 

Needles and needle- 
holder. 



Scissors. 
Forceps. 
Knives. 



Varicocele and Hydrocele 

Grooved director. Needles and needle- 

Hemostats. holder. 



140 



SURGICAL TECHXIC 






Fig. 114. — Goodell-Lentz uterine Fig. 115. — Simpson's Fig. 116. — Placental 
dilator. uterine sound. forceps. 




Fig. 117. — Uterine dilator. 



INSTRUMENTS 



141 





Fig. 118. — Bone chisels, gouge, osteotome (Macewen's), Fig. 119. — Bone 
and mallet. gouge. 




Fig. 120. — Bone-cutting forceps. 



142 



SURGICAL TECHNIC 




Fig. 121. — Thompson's evacuating stone-searcher. 




Fig. 122. — Gouley's tunneled catheter threaded on a filiform bougie. 




Fig. 123. — Lithotrite. 




Fig. 124. — Bigelow's evacuator. 



INSTRUMENTS 



143 



Catheters, Varieties of, Including Gouley 
See pictures of all varieties. 



Electric attachments 

for cystoscope. 
Syringe. 
Urethroscope. 



Cystoscopy 
Knife, small. 
Key's installator. 
Irrigating apparatus. 
Local anesthetic. 



Catheters. 
Sterile glycerin. 



Knives. 

Forceps, phimosis. 



Circumcision 
Scissors. 
Needles. 



Hemostats. 
Needle-holder. 



Rectum, Resection of 



Knives. 
Scissors. 

Double tenaculum. 
Retractors, toothed 
and plain. 



Forceps. 

Specula. 

Probe. 

Clamp and cautery. 

Hemostats. 



Proctoscope. 
Grooved director. 
Needles and needle- 
holder. 



Same as above. 



Hemorrhoids 




Fig. 125. — Gant's pile clamp. 



CHAPTER VIII 

ANESTHESIA 

Anesthetics are divided into three classes: local, 
spinal, and general. 

Local anesthetics are agents which abolish sensation 
by their local action on the sensory nerves. 

Spinal anesthetics are those that produce anesthesia by 
their action upon the spinal ganglion within the spinal 
canal. 

General anesthetics are those which produce loss of 
consciousness. 

No general rule can be given as to the selection of the 
anesthetic, but in describing each we will indicate where 
it is best applicable. 

Preparation for Anesthesia and Precautions. — A pre- 
liminary preparation of the patient is advisable before the 
administration of a general anesthetic. The anesthetic 
is taken better if the patient has been placed upon a light 
diet for several days and the bowels regulated. Upon 
examination of the patient it may be found advisable 
to give a special preparation for several weeks in order to 
secure the best results from the operation. Where only 
a light anesthesia is administered, such as nitrous oxid 
(laughing-gas), practically no preparation is necessary. 

Care of the Bowels. — Whenever possible the intestinal 
canal should be emptied several hours before the ad- 
ministration of the anesthetic. The usual method is 
144 



ANESTHESIA 1 45 

to give a cathartic, such as castor oil, magnesia citrate, or 
magnesium sulphate, the night before and a low soapsuds 
enema two hours before the operation. 

Frequently it will be found to be impossible to carry 
out the above procedure. In such cases a high purgative 
enema is advisable, 

Diet. — For twenty-four hours before the operation a 
light diet should be taken. If the operation is to take 
place in the morning, practically no food should be taken 
after 8 p.m. the night before. If the operation is to 
take place in the afternoon, nothing should be taken after 
8 A. M. If the patient complains of weakness or great 
hunger a cup of beef-tea may be given up until within 
three hours of the operation. If the stomach is full at 
the time of operation, vomiting usually occurs, thereby 
adding to the dangers of the anesthetic. 

In cases of emergency, preliminary washing out of the 
stomach is advisable, especially if the operation is upon 
the stomach. 

It should always be practised if the operation is for 
intestinal obstruction, because in intestinal obstruction 
patients have drowned from vomiting occurring during 
anesthesia. 

Preparation of Mouth and Teeth. — It is advisable to 
thoroughly cleanse the teeth with a tooth-brush, and if 
marked Riggs' disease exists, paint the roots of the 
teeth with iodin, in this way lessening the danger of 
aspiration pneumonia. 

Preliminary Use of Drugs. — The patient should have 
a good night's sleep before the operation. Some patients 
will sleep without any assistance; others will require 
trional or bromids. Many surgeons order a morphin 



146 



SURGICAL TECHNIC 



hypodermic one hour before the anesthesia. It has the 
advantage of lessening the stage of excitement and the 
amount of anesthetic required. It is especially indicated 
in excitable, vigorous, and alcoholic patients. The chief 
objections are that it has a tendency to diminish respira- 
tion and masks symptoms of overnarcosis. It is contra- 
indicated in children and in the age 

Atropin or scopolamin is frequently combined with the 
above to diminish the amount of secretion. 




Luer's hypodermic syringe. 



Physical Examination. — A thorough examination is 
necessary if one would have a low ether mortality, for 
in this way contra-indications will be detected. This 
should include complete physical, blood-pressure, and 
urine examinations. When possible, the total elim- 
ination for twenty-four hours should be noted. For 
example, if albumin be present, it would be advis- 
able, when possible, to delay the operation until the 
kidneys have returned to the normal, or to use some 
other form of anesthetic. If sugar is found to be present 
in the urine, the amount of . acetone or diacetic acid 
should be noted and the patient carefully prepared. In 



ANESTHESIA 



H7 



the case of high blood-pressure, it might be advisable to 
use a local anesthetic. 




Care of the Patient. — When the patient is placed upon 
the operating-table, care should be taken to maintain 
the body heat and to prevent chilling. Frequently we 
find that patients are allowed to lie for several minutes 



I48 SURGICAL TECHNIC 

in pools of water or in damp towels. The patient should 
be made as comfortable as possible upon the operating- 
table and a small pillow should be placed in the hollow 
of the back to prevent postoperative backache. 

Before the anesthetic is administered it should be 
noted that there are no tight bandages or clothing around 
the neck or chest. The mouth should be carefully ex- 
amined and false teeth removed so that they do not fall 
into the larynx and cause obstruction. 

Be sure to have the patients securely fastened so that 
:annot injure themselves or the assistants. 




Fig. 128. — Griffith's single-eared anesthetizing stethoscope, which will 
enable the anesthetist to have constant knowledge of the patient's heart 
and respiratory action while allowing the hands to be free. 

Anesthetist's Supplies. — Besides the apparatus used 
by any particular anesthetist, there should be a mouth- 
gag, wedge-shaped tongue forceps, hypodermic syringe, 
camphor, adrenalin, atropin. strychnin, sponge-holders, 
sponges, and small pus basin. Oxygen apparatus should 
be ready for use. 

Stages of Anesthesia. — Anesthetics usually have three 
stag- - 

First — Stage of irritation. 

Second — Stage of excitement. 

Third — Stage of surgical anesthesia. 



ANESTHESIA 1 49 

First Stage. — A few preliminary whiffs produce an 
irritation of the mucous membrane, with coughing and 
secretion of mucus and a temporary holding of the 
breath. If the vapor is given too rapidly or in too con- 
centrated form, violent coughing will occur and the 
patient will experience a sensation of suffocation. If 
given slowly, drop by drop, these symptoms will be 
obviated or greatly diminished and the patient will be- 
come etherized with a slow increase of the pulse and res- 
piratory rate; pupils react to light, but there will be 
moderate dilatation and the conjunctival reflex is present. 

Second Stage. — The patient now passes into the stage 
of excitement, in which he talks, laughs, and hallucina- 
tions are present. He sometimes throws his arms around, 
tries to tear off the mask, and injures the assistants unless 
he is securely held down. Here the anesthetic should be 
rapidly pushed until the stage of surgical anesthesia is 
reached. 

Third Stage. — Now one notices a general relaxation; 
the pulse becomes slow and regular, the breathing super- 
ficial, with a more or less snoring sound; pupils are mod- 
erately contracted; the conjunctival and more superficial 
reflexes disappear and the patient is ready for operation. 
The conjunctival reflex is obtained by drawing up the 
upper lid and noting whether the lower lid contracts 
toward the nose. 

It is now that the skill and experience of the anesthe- 
tizer will be determined. If the anesthetic is dropped 
slowly and uniformly the patient will be kept on the 
border-line of surgical anesthesia. The danger signs 
are increased, pulse-rate slower, dilatation of the pupils, 
which react less promptly to light. 



I50 SURGICAL TECHNIC 

If the pupils dilate and the conjunctival reflex is pres- 
ent, you will know that the patient is coming out. The 
art of anesthetizing is that of keeping midway between 
the two. 

The less anesthesia administered, the more rapid the 
recovery. Vomiting frequently occurs, laughing or cry- 
ing, and the gradual recovery of the mental equilibrium. 
At times patients will pass into a deep sleep which will 
last for several hours. 

Ether Anesthesia. — Ether is a colorless, volatile, 
sweetish liquid. It is very inflammable and should not 
be administered near an open flame, cautery, or x-ray 
tube. If artificial light is necessary it should be high 
above the patient, as ether fumes tend to sink downward. 
The ether fumes are irritating to the mucous membrane 
and frequently produce increased secretion of saliva. 
It is estimated that ether is about fifty times as safe as 
chloroform. The reason is that it is less rapid in its 
action and the danger signs appear earlier, and it is 
slower in its action than chloroform. 

Suitable Cases. — When a general anesthetic is neces- 
sary and the operation is not suited to nitrous oxid, ether 
is preferable in the average case to all other anesthetics. 
On account of its irritating action ether should be 
avoided in cases of bronchitis, lung trouble, or in ad- 
vanced Bright's disease. Ether may be administered 
by an expert by the drop method, semi-open, closed, or 
the vapor method, but with the novice or beginner the 
open method is the safest. 

Open Method. — Any of the chloroform masks are satis- 
factory, or several layers of gauze resting on the ether- 
izer's hand. A new can of ether should be opened for 



ANESTHESIA 



151 



each anesthetic, as in this way pure ether will always be 
obtained. Some manufacturers have cans with special 
dropping mouths attached. 




Fig. 129. — Vapor apparatus for anesthesia: A, bottle containing hot 
water and essence of orange; B, ether bottle; C, chloroform bottle for 
ether or chloroform at discretion of anesthetist; D, mask for ordinary 
anesthesia, connected to bottles by delivery tube E; F, Lombard nasal 
tubes for nasal insufflation anesthesia; G, vapor delivering mouth-gag for 
work about the mouth and throat; N, foot-pump. (Fowler's Operating- 
room and the Patient.) 



Semi-open method, such as Allis' inhalers, consists of an 
outer metal form provided with slots through which a 
cotton or flannel bandage is threaded. 

Closed Inhaler. — This consists of a closed face-piece 



152 



SURGICAL TECHNIC 



surrounded by an inflatable rubber rim. connected to a 
chamber and rubber bag filled with gas. The chambers 
have openings so that air or the anesthetic may be intro- 
duced, or rebreathing may be obtained by closing the 
openings. To obtain the benefits of warm vapors, the 
bottles of the inhalers are heated. 

Vapor Method. — This method is especially indicated 
in operations around the mouth and throat. It can 
be administered bv a tube introduced into the mouth or 




AlhY aseptic ether inhaler. 



nose. The Gwathmey apparatus is as satisfactory as 
any. and as described by himself consists of two 6-ounce 
bottles, one for chloroform and one for ether. Both are 
placed in a tin vessel containing warm water. If the 
heat is to be continued, renew the water from time to 
time. In each of the bottles there are three tubes, vary- 
ing in length from one that reaches to the bottom of the 
bottle to one that penetrates only the stopper. These 
represent three degrees of vapor strength. By turning a 
cock at the mouth of the bottle ether or chloroform mav 



ANESTHESIA 



153 



be used, or by turning another cock pure air or oxygen 
may be given. By pressing the hand-bulb air or oxygen 
may be forced into the apparatus and the ether or chlo- 
roform is carried to the patient by a tube. Whatever 
inhaler is used, the part that comes in contact with the 
patient should be sterilized. 




Fig. 131. — Showing the administration of ether by the drop method. 
(Morrow's Diagnostic and Therapeutic Technic.) 



Drop Method. — The eyes of the patient should be pro- 
tected by a folded towel or piece of rubber dam and the 
mask or gauze placed over the mouth. The patient is 
instructed to breathe naturally and regularly. After 
several breaths have been taken, a few drops of ether are 
dropped upon the mask. If the patient struggles, coughs 



154 SURGICAL TECHNIC 

or chokes, the mask should be removed and the procedure 
started again. When the stage of excitement is reached, 
less time should be allowed to elapse between the drops, 
but care should be exercised not to change the rate of 
dropping too suddenly, as this has a tendency to irritate 
the respiratory tract by its density, thereby causing the 
patient to choke or hold his breath. By the drop 
method it is possible for the patient to lose conscious- 
ness without moving in about fifteen to twenty minutes. 
As soon as the patient reaches the stage of surgical 




Fig. 132. — Proper method of holding the jaw forward. (Morrow's 
Diagnostic and Thereapeutic Technic.) 

anesthesia only sufficient ether should be given to keep 
him under its influence. During the anesthesia the 
pulse-rate, respiration, and eye reflexes should be fre- 
quently noted. To prevent the tongue from falling back 
and causing obstruction the jaws should be held forward 
by placing the fingers back of the angle, for if the jaw is 
pushed forward, the tongue, which is attached to it, 
will also be pushed forward. If the tongue continues 
to drop back, it should be held forward by tongue forceps 
or a thread, or a heavy piece of silk pierced through the 



ANESTHESIA 



155 



tip by means of a needle. The tongue forceps should 
consist of two sharp points so that they will make one 
puncture, rather than the forceps frequently advised, 
which crush the tongue. 

If vomiting occurs, the inhaler should be removed 
and the patient's head turned to one side, the vomitus 
removed from the mouth with a swab, the mouth 
cleansed, and the ether pushed. 

Semi-open Method. — It is essentially the same as the 
preceding, except that the ether is dropped upon the 
mask. 

Chloroform Anesthesia. — Chloroform is a clear, color- 
less liquid with a characteristic odor. When used for 





Fig. 



133. — Griffith's wire-frame 
chloroform inhaler. 



Fig. 134. — Griffith's chloroform 
inhaler covered with square of 
double-thickness gauze. 



anesthetic purposes it should be pure and absolutely 
fresh and neutral to litmus- paper. It should always be 
kept in dark bottles in a cool place. Under the influences 
of light and heat it frequently decomposes into a hydro- 
chloric acid, chlorin, and other impurities. It is very 
irritating to the skin and mucous membranes. For 
this reason the face should be anointed with vaselin. 
The beginner should give chloroform by the open 
method and the anesthesia should proceed very cautiously 
and slowly. It is less irritating to the respiratory tract, 



156 SURGICAL TECHNIC 

more agreeable to take, quicker in its action, and con- 
sciousness returns more rapidly. Fatalities from it are 
sudden and without premonitory signs. It is best ad- 
ministered warm and with the head low. Always re- 
member to pay minute attention at all times. Do not 
confuse with ether, where large amounts are required to 
produce anesthesia. Here only a few drops are neces- 
sary. At present it is considered a dangerous anes- 
thetic, as it causes subsequent changes in the liver and 
other organs. It is safer in the presence of a cautery or 
open flame, as it is not inflammable. Its use at the 
present time is becoming more limited. 

Nitrous Oxid Anesthesia. — Nitrous oxid is a colorless 
gas heavier than air. It is sold in liquid form in steel 
containers, from which when liberated it escapes as a 
gas. It has anesthetic properties, but its result is mostly 
due to diminution of the amount of oxygen inhaled. It 
is considered the safest anesthetic. The death-rate is 
said to be 1 in 100,000. When used with the proper 
admixture of air or oxygen, anesthesia may be con- 
tinued indefinitely. The amount of oxygen necessary 
is from 8 to 18 per cent. Nitrous oxid is very rapid in 
its action and produces complete unconsciousness in 
about two minutes, and the patient recovers in approxi- 
mately the same time. The disadvantages of nitrous 
oxid are that it does not produce complete relaxation 
and requires a complicated apparatus for its administra- 
tion. It is contra-indicated in any obstruction of the air- 
passages. For long operations it is advisable to precede 
it by preliminary medication of morphin. 

Apparatus. — It consists of a mask with a pneumatic 
rim which accurately fits the face. This is connected to 



ANESTHESIA 1 57 

a chamber which has valves or openings for intake and 
outgo joined with rubber bags into which the oxygen and 
nitrous oxid flow. These openings may be controlled by 
a switch to definitely establish the administration, or by 
valves which the operator controls, increasing or dimin- 
ishing the quantity as indicated. Most apparatus have 
a rebreathing chamber attached, so that the same gases 
are used several times, in this way diminishing the 
amount of oxygen and nitrous oxid. 

All parts which come in contact with the patient should 
be carefully sterilized after using. 

Administration. — In giving pure nitrous oxid for short 
operations the apparatus is connected with a supply 
cylinder and the rubber bag partially filled with gas. The 
face-piece is then applied to the mouth and nose so that 
air cannot enter around the rim; the outlet valve is 
opened and the patient is requested to breathe. After 
two or three inhalations, when the patient has become 
accustomed to the apparatus, the stop-cock is opened and 
the gas is allowed to enter the bag. In this way the 
patient breathes pure nitrous oxid. After the first few 
inspirations of gas the face gradually changes color and 
becomes dusky and finally a dark blue. There is usually 
at first a mumbling speech which is rapidly followed by 
snoring, and at times rigidity of the muscles. A minor 
operation may now be performed, as the surgical anes- 
thesia will last approximately two minutes. Reaction 
is rapid and the face gradually assumes its normal color. 
For long operations sufficient oxygen to keep the patient 
just under the point of unconsciousness is allowed to 
enter the bag. Duskiness of the skin and irregular 
breathing is a signal for more oxygen. Often anesthesia 



158 



SURGICAL TECHNIC 



is best obtained from the form of apparatus by which the 
percentage of oxygen can be regulated. 

Nitrous Oxid and Ether. — The patient is first anes- 
thetized with gas, which is either continued with ether or 




Fig. 135. — Griffith's combined inhaler for gas and liquid anesthetics. 

the admixture of ether and nitrous oxid. This is the 
most careful method of anesthetizing and gives the relax- 
ation required, at the same time diminishing the amount 




Fig. 136. — Ethyl chlorid tube. (Morrow's Diagnostic and Therapeutic 
Technic.) 

of anesthetic necessary. The ether is admitted to the 
chamber by a special dropper which can be regulated. 
Ethyl chlorid is a harmless volatile liquid. For general 



ANESTHESIA 



159 



anesthetic purposes only the pure product should be used 
and the bottle should be labeled "For General Anes- 
thesia." It is put up in metal or glass containers with a 
special spring stop-cock. Anesthesia is produced in from 
thirty to sixty seconds, and is continued until from two to 
three minutes after the anesthetic has been discontinued. 




Fig. 137. — Mask and tube for ethyl chlorid (Hirst). 



It is more dangerous than nitrous oxid, but is frequently 
followed by headache, nausea, vomiting, etc. Its ad- 
vantage is that it may be administered without any 
special apparatus. It is used for short operations or as a 
preliminary to a general anesthetic. It is dangerous 
and should not be used except by some one with special 
training. 



l6o SURGICAL TECHNIC 

SPECIAL METHODS OF ANESTHESIA 

Intrapharyngeal Inhalation Anesthesia. — In operations 
about the mouth, face, etc., this method, by which tubes 
are passed into the pharynx through the nose (Crile's 
method), will be found to be very convenient. The 
advantages are that the anesthetizer and his apparatus 




Fig. 138. — Showing the method of inserting the tubes and packing the 
pharynx for intubation anesthesia. (Morrow's Diagnostic and Thera- 
peutic Technic.) 

are removed from the field of operation so that he will 
not interfere with the operator, nor will the operator have 
to stop at frequent intervals while more anesthetic is 
being administered, as is necessary in the ordinary 
method of anesthesia. The pharynx may or may not be 
packed with gauze. 



ANESTHESIA l6l 

The apparatus consists of two rubber tubes that can 
be passed through the nose. They are about 8 inches 
long and have side openings cut into the lower 2 inches. 
The outer ends are connected to two ends of a Y-shaped 
tube, the other end of which is connected to a funnel by 
a rubber tube. The funnel is loosely packed with gauze. 

Technic. — After full anesthesia has been produced by 
the usual method, a mouth-gag is inserted, the throat 
cleared of mucus, and two tubes well lubricated are passed 
through the nose down into the lower back part of the 
pharynx. At this point the pharynx may or may not 
be packed with gauze. The tubes are then connected 
as described above and the anesthetic is continued by 
dropping the ether upon the gauze in the funnel. After 
the operation is completed the tubes are gently removed. 

Intratracheal Insufflation Anesthesia. — Intratracheal 
anesthesia, first developed by Meltzer and Auer, consists 
in the introduction into the trachea of a flexible woven 
tube which is slightly less in diameter than the lumen of 
the trachea. This tube is connected to a special ap- 
paratus by which air and ether are forced through the 
tube into the trachea. The space between the tube 
and the trachea permits the exhalation of air from the 
lungs. By this method it has been found that it is not 
necessary for respiration to take place at all, as the inter- 
change of oxygen, etc., is carried on by the continuous 
entrance and exit of air. It was especially developed for 
operations upon the chest and in cases of respiratory 
paralysis. It is now used for operations upon the mouth, 
etc., as the continuous reflux of air prevents blood from 
being sucked into the larynx and thereby causing pneu- 
monia. It is also frequently used in operations upon 
11 



1 62 SURGICAL TECHNIC 

the head, neck, and brain, as by this method the anes- 
thetizer is away from the field of operation and in this 
way lessens the danger of sepsis. 

Apparatus. — There are several good intratracheal 
insufflation machines on the market, such as Elsberg's, 
Janeway's, Boothby's, and Miiller's, which are elaborate 
in their completeness. A very simple and inexpensive 
apparatus which answers all purposes is described by 
Meltzer (Keen's Surgery, Vol. VI) as follows: 

"By means of a glass-blower's foot-bellows (B) air is 
driven through a system of branching tubes into the in- 
tracheal tube (In.-T.). The first branching of the tubes 
is introduced for the purpose of regulating the inter- 
ruption of the air-stream. From the right branch a 
tube is led off laterally, carrying a stop-cock (St. 3) which 
is to be used for the interruptions of the air-current. 
During the opening of the stop-cock a part of the air- 
current continues through the left tube, thus preventing 
too great a reduction of the pressure, which is undesir- 
able. By means of a screw-clamp (S. C.) the amount 
which is to pass through the left tube can be regulated; 
a narrowing of this tube causes a greater collapse of the 
lung during the interruption. The second branching of 
the tubes is introduced for the purpose of regulating the 
anesthesia. The ether bottle (E) is interpolated in the 
left branch ; the right branch runs uninterrupted outside 
of the bottle to unite with the part of the left tube which 
comes from the ether bottle. When the stop-cock in the 
right branch (St. 2) is closed, all the air passes through 
the ether bottle; when, instead, both stop-cocks in the 
left branch (St. 1 and St. 4) are closed, only pure air 
reaches the intratracheal tube, and when all three stop- 



ANESTHESIA 1 63 

cocks are open only one-half of the air is saturated with 
the anesthetic. By partial closing of the stop-cocks vari- 
ous degrees of anesthesia can be obtained. The third 
opening in the ether bottle carries a tube with a funnel 
(F) through which the bottle is filled with the anes- 
thetic ; the tube is otherwise kept tightly closed by means 
of a screw-clamp (S. C). All three rubber stoppers 
are firmly and permanently wired down to resist various 
pressures. When the ether bottle is to be refilled during 
insufflation both stop-cocks on the left side are closed, 
while the one on the right side is open. 

"The tube which connects the anesthesia circle of tubing 
with the intratracheal tube (In.-T.) carries two lateral 
tubes; one is connected with a manometer (M.), which 
needs no description, and the other leads to a safety- 
valve (S. V.) of simple construction. To the rubber 
tubing is attached a graduated glass tube, the lower end 
of which is immersed under the surface of the mercury 
in this bottle to a depth corresponding to the pressure 
which is desired for the intratracheal insufflation. For 
instance, if the pressure should be not more than 20 mm. 
of mercury, the glass tube is immersed just 20 mm. below 
the surface of the mercury. The glass tube is kept in the 
desired place by means of a rubber ring resting upon the 
opening of the mercury bottle. This device gives great 
safety to the working of the method. No matter how 
strong and irregular the bellows is worked, the intra- 
tracheal pressure could never rise above the one arranged 
for; the surplus of air escapes through the tube from 
under the mercury." 

The tracheal tube should be flexible and elastic, about 
14 inches (35 cm.) long, with a mark 10J inches (27 cm.) 



1 64 



SURGICAL TECHNIC 



from the distal end and with the opening preferably at the 
end. A silk-woven catheter, No. 22 to 24 French, and 




for children of a correspondingly small size, is frequently 
used. There will be required in addition a mouth-gag 
and a Jackson's direct view laryngoscope (Fig. 140). 



ANESTHESIA 



165 



Elsberg has devised a special bit or holder to keep the 
tube from slipping up or down after it has been properly 
introduced, but in its absence adhesive plaster may be 
employed for this purpose. 

Asepsis. — The tracheal tube and the laryngoscope 
must be sterile. 

Preparation of Patient. — The patient is prepared in 
the usual way as for any other anesthetic. 




Fig. 140. — Jackson's direct view laryngoscope. (Morrow's Diagnostic 
and Therapeutic Technic.) 



Technic. — The patient is etherized by the open method 
and the tube introduced into the larynx by means of a 
Jackson laryngoscope, with the head well extended. No 
force should be used upon the tube. After it has been 
introduced the Jackson speculum should be removed. 
The tube should be pushed down until a slight resistance 
is felt. It should then be withdrawn approximately 2 
inches which is indicated by a white mark upon the tube. 
Care should be used to see that the tube is in the trachea 
and not in the esophagus. This is determined by the 



166 SURGICAL TECHNIC 

fact that air will not be drawn in and out through the 
tube if it is in the esophagus. After it has been deter- 
mined that the tube is in the trachea, the tube should be 
connected to a special apparatus which prevents it from 
changing its position. It is then connected to the intra- 
tracheal apparatus with the air under the pressure of 15 
to 20 mm. of mercury. After the operation is completed 
the ether is discontinued and pure air insufflated for a 
minute or two, and then the tube is withdrawn. 

Rectal anesthesia consists of producing etherization 
by means of a warm ether vapor gradually introduced 
into the rectum. This method has been more or less 
abandoned on account of the irritation of the ether, which 
produced colicky pains, diarrhea, and at times distention 
of the intestines. With the improved technic of Cun- 
ningham these faults are said to have been eliminated. 

Oil-ether Colonic Anesthesia. — Recently Gwathmey, 
of New York, has developed a method of rectal anes- 
thesia by means of a mixture of olive oil and ether in- 
jected into the rectum, to which he applies the name ''oil- 
ether colonic anesthesia" (New York Medical Journal, 
Dec. 6, 1913). 

Scopolamin-morphin Anesthesia, "Twilight Sleep." — 
Hypodermic injections of scopolamin or hyoscin (which 
are claimed to be chemically the same) have been used 
in combination with morphin to produce anesthesia. 
From the number of deaths reported from this combina- 
tion it would appear to be a very dangerous form of 
anesthesia. "Twilight sleep" is the frequent hypodermic 
administration of small doses of the above. In small 
doses, however, hyoscin and morphin may be used with 
good results as an adjunct to local or general anesthesia. 



ANESTHESIA 167 

In such cases they can be given as follows: Hyoscin, gr. 
y^j (0.00065 gm.), and morphin, gr. J to J (0.0108-0.0162 
gm.), by hypodermic, one to two hours before operation. 
This combination is more efficacious than morphin alone, 
and has the effect of producing a drowsy state and even 
sleep, which may last five to six hours after the operation. 
It is contra-indicated in patients with heart disease or 
when there is a tendency to pulmonary edema. In the 
young and the aged hyoscin and morphin should be used 
with great caution. 

Postoperative Anesthetic Paralyses. — These are usu- 
ally peripheral in origin, and are due to pressure upon the 
nerve during the period of unconsciousness. At times 
paralysis due to cerebral hemorrhage may occur during 
anesthesia. Paralysis due to pressure may affect the 
arm, leg, or face. The most frequent form encountered 
is wrist-drop, due to pressure upon the musculospiral 
nerve, and is caused by the arm being allowed to hang 
over the table, or by injury to the brachial plexus while 
the patient is in the Trendelenburg position. 

Delayed Poison. — Many deaths formerly credited to 
anesthesia, shock, and hemorrhage are now known to be 
due to acid intoxication. The symptoms do not appear 
for several hours after the operation. Persistent vomit- 
ing is frequently due to acid intoxication. Sodium bicar- 
bonate, by the mouth, may be given as a preventive, or 
after the operation by enteroclysis or hypodermoclysis. 
It is considered the most valuable remedy at our com- 
mand. This should be assisted by free elimination from 
the skin, bowels, and kidneys. 



1 68 SURGICAL TECHNIC 

LOCAL ANESTHESIA 

Local anesthetic agents are divided into two classes: 
those which act by freezing the part, such as cracked ice 
and salt, ether, and ethyl chlorid; and those which act 
directly upon the sensory nerves, as cocain, novocain, 
eucain, alypin, akoin, tropocain, stovain, and phenol. 

Cracked Ice and Salt. — Take \ pound of cracked ice 
and mix thoroughly with J pound of salt. This is applied 
to the part from ten to fifteen minutes. The part be- 
comes tallowy -white and anesthetic. The objections to 
this form of anesthesia are : it offers great resistance to the 
knife, it devitalizes the tissue, and produces a sensation 
of burning after the part has thawed. 

Ethyl Chlorid. — It is sprayed upon the part and evapo- 
rates quickly, and in so doing it carries off the heat and 
produces anesthesia. Ether acts in the same manner 
locally applied. 

The objections to these agents are: they produce a 
resistance to the knife, a burning sensation, and conges- 
tion of the vessels of the part after thawing. 

Cocain. — It was first used as a local anesthetic in the 
eye clinic of Dr. Koller (1884) when he succeeded in anes- 
thetizing the conjunctiva by instilling a few drops of a 4 
per cent, solution of cocain into the eye, anesthesia re- 
sulting five minutes after the instillation. 

Cocain when applied to any mucous surface is ab- 
sorbed readily and anesthetizes the sensory nerve-endings 
of the part. It is, therefore, very useful in operations 
upon the nose, throat, ear and eye, urethra and bladder, 
and is administered internally for its anesthetic action 
on the mucous membrane of the stomach in cases of 
vomiting. 



ANESTHESIA 1 69 

When employed to anesthetize the skin, local applica- 
tion of the anesthetic solution will not suffice, and it is, 
therefore, necessary to inject the solution hypodermic- 
ally, when the nerve-endings in or under the skin are 
* rendered insensitive by being bathed in the solution 
employed; this process is called infiltration anesthesia. 

Conduction anesthesia is the interruption of the con- 
ductivity of smaller or larger nerve branches which sup- 
ply a given tissue complex. 

Endoneural anesthesia is the injection of the anesthetic 
solution into the nerve-tissue. 

Perineural anesthesia is the injection of the anesthetic 
solution into the tissues surrounding the nerve. 

Cocain is a very powerful local anesthetic having an 
extreme toxic action which may readily poison the patient, 
resulting in delirium, talkativeness, and respiratory par- 
alysis. It is very difficult to sterilize, as it decomposes on 
boiling, forming ecgonin, which has no anesthetic value; 
it is, therefore, necessary to use fractional sterilization or 
add carbolic acid, which makes it less valuable. 

Cocain is used in solutions varying from I to 10 per 
cent. It is never necessary to use over I per cent, 
solution for infiltration anesthesia. When applied locally 
to mucous surfaces it may be used up to 10 per cent. 

The following are the formulas for the solutions used 
by Schleich for producing local anesthesia: 

No. I — Strong 

Cocainge hydrochloridi gr. iij; 

Morphinae hydrochloridi gr. §; 

Sodii chloridi (sterilized) gr. iij ; 

Aquae destillatae (sterilized) q. s. f Biij, f 3iiss. 



I70 SURGICAL TECHNIC 

No. II — Normal 

Cocainae hydrochloridi gr. iss; 

Morphinae hydrochloridi gr. § ; 

Sodii chloridi (sterilized) gr. iij ; 

Aquae destillatae (sterilized) q. s.. f oiij, foiiss. 

No. Ill— Weak 

Cocainae hydrochloridi gr. i; 

Morphinae hydrochloridi gr. u; 

Sodii chloridi (sterilized) gr. iij; 

Aquae destillatae (sterilized) q. s.. f o iij , foiiss. 

One drop of a 40 per cent, solution of formalin should 
be added to each of these solutions to preserve them. 
The fluid is injected in such a manner that the part to be 
operated upon is completely surrounded by wheals of the 
injected fluid. 

The dose should be in proportion to the extent of the 
surface to be anesthetized, but should never exceed i| 
gr. It is well to divide the dose into several portions, 
leaving an interval of several minutes between each 
injection. If toxic manifestations follow the first por- 
tion, further injection must be abandoned. 

Treatment of Cocain-poisoning. — Give morphin and 
atropin hypodermically, or administer chloral hydrate, 
chloroform, alcohol, or ether; these are physiologic 
antidotes. 

For cardiac weakness strychnin should be adminis- 
tered. A large teacupful of coffee, administered either 
hot or cold, has proved very beneficial in this condition. 

Novocain, introduced by Braun, is a white crystalline 
powder, soluble in water, is less toxic than cocain in 
proportion to its local anesthetizing power, does not 
cause damage to the tissues, is easily sterilized when in 
solution, and is capable of being combined with adren- 



ANESTHESIA 171 

alin. It can be heated to 120 C. without decomposi- 
tion, and large doses may be employed without toxic 
effects — 7! to 22J gr. have been employed without un- 
pleasant symptoms resulting. It is seven times less 
toxic than cocain and one-third less than any of the 
other substances mentioned. Vomiting is not rare after 
injection, but is free from significance. 

The toxic symptoms are nausea, sweating, pallor, 
weak pulse, acceleration of the respiration, feeling of 
oppression, and vomiting. 

Solutions employed are 0.5 to 1 or 2 per cent., the 
former two usually being sufficient for the production 
of conduction anesthesia. Where there are thick nerve 
trunks 2 or 3 or even 4 per cent, have been employed. 

There are tablets on the market containing 0.125 gm. 
of novocain and 0.00012 gm. of suprarenin. One tablet 
dissolved in 25 c.c. of sterile physiologic salt solution will 
give a 0.5 per cent, solution. 

To 1 liter of physiologic salt solution should be added 
3 drops of hydrochloric acid to preserve the adrenalin 
during the process of boiling. 

Eucain occurs as a white powder, soluble in water, can 
be boiled, is less toxic than cocain, but is not as strong an 
anesthetic. 

Alypin, akoin, and tropacocain are other drugs which 
are used in place of cocain because their anesthetic value 
is not destroyed by boiling and they are less toxic in 
their action, but novocain is by far the superior of these 
agents, as has been proved by results. 

Phenol has been used, acting both as an antiseptic and 
anesthetic, but sloughing has frequently followed its use, 
and for this reason it is no longer used for this purpose. 



172 



SURGICAL TECHNIC 
SPINAL ANESTHESIA 



The injection of anesthetic fluid into the spinal canal. 
The entire technic must be done under strict surgical 
asepsis. A solution of iodin, full strength, should be 
applied locally to the entire back by means of a sterile 
gauze sponge. A line drawn parallel with the superior 
border of the crests of the ilia divides the fourth lumbar 




Fig. 141. — Apparatus for spinal anesthesia: 1, Ethyl chlorid; 2, medi- 
cine glasses, one for receiving the spinal fluid and the other for the anes- 
thetic solution; 3, ampule containing sterile cocain and salt crystals; 4, 
scalpel; 5, syringe and trocar. (Morrow's Diagnostic and Therapeutic 
Technic.) 



spine. Have the patient in the sitting position, with 
arms folded upon the chest and bending forward; this 
being done to widen the interspaces. 

A platinum or iridoplatinum needle about 3 inches 
long should be used for this purpose. The needle should 
contain a trocar and be properly beveled. 

When the needle has passed into the deeper structures 
the trocar is removed and the needle is tilted downward 



ANESTHESIA 



173 




Fig. 142. — Points for injecting the anesthetic solution in spinal anesthesia. 
(Morrow's Diagnostic and Therapeutic Technic.) 




Fig. 143. — Showing the method of locating the fourth spinous process 
by passing a line through the highest points of the iliac crests. (Morrow's 
Diagnostic and Therapeutic Technic.) 



174 SURGICAL TECHNIC 

and pushed gently forward in the direction of the canal. 
When the needle has entered the canal drops of spinal 
fluid will exude. Allow about the same amount of fluid 
to escape as you intend to inject into the canal. 

Now attach the barrel of the hypodermic syringe to the 
needle and inject the anesthetic solution. Remove the 




Fig. 144. — Showing the direction of the needle in entering the spinal canal. 
(Morrow's Diagnostic and Therapeutic Technic.) 

needle quickly and place patient in the recumbent posi- 
tion. If the solution is injected into the fourth lumbar 
interspace anesthesia will be incomplete at the level of 
the navel, and if it is injected into the second lumbar in- 
terspace anesthesia of the entire abdomen will be com- 
plete. 

If the solution used has a lesser specific gravity than 



ANESTHESIA 



175 




Fig. 145. — Spinal anesthesia. First step, nicking the skin at the site of 
puncture. (Morrow's Diagnostic and Therapeutic Technic.) 




Fig. 146. — Spinal anesthesia. Second step, inserting the needle. (Mor- 
row's Diagnostic and Therapeutic Technic.) 



176 



SURGICAL TECHNIC 




Fig. 147. — Spinal anesthesia. Third step, allowing the cerebrospinal 
fluid to escape. (Morrow's Diagnostic and Therapeutic Technic.) 




Fig. 14S. — Spinal anesthesia. Fourth step, injecting the anesthetic solu- 
tion. (Morrow's Diagnostic and Therapeutic Technic.) 



ANESTHESIA 177 

the spinal fluid the head and upper portion of the body 
should be lowered, and the opposite position assumed if 
the solution has a greater specific gravity. 

A solution used for this purpose having a lower specific 
gravity than the spinal fluid is that of Babcock. The 
solution is on the market in glass ampules hermetically 
sealed and consists of the following: 

Babcock's Formula 

(Approximately.) 

(A) Stovain 0.08 gm.. 

Lactic acid 0.04 c.c. 

Absolute alcohol 0.2 c.c. . . 3 minims. 

Distilled water 1.8 c.c 30 minims. 



(B) Tropacocain 0.1 gm.. 

Absolute alcohol . . t ... . 0.2 c.c. 

Distilled water 1.8 c.c. 



if gr. 
3 minims. 
30 minims. 



(C) Novocain 0.16 gm.. 

Absolute alcohol 0.2 c.c. . . 3 minims. 

Distilled water 1.8 c.c. . . 30 minims. 

Dose. — 1 to 1.5 c.c (16-25 minims) of these mixtures is given to 
adults. 

Postoperative Treatment. — The foot of the bed should 
be elevated for at least two hours. If vomiting occurs, 
give cracked ice; for headache, application of ice-cap 
affords great relief. 

Contra-indications. — Very nervous patients, children, 
the very aged, and scoliotics. 

Never use old solutions, as this is frequently the cause 
of severe headache. 



CHAPTER IX 

GAUZE SPONGES; PADS; DRESSINGS; TAMPONS; 
DRESSING-ROOM OUTFIT; DRAINAGE, CARE 
OF DRAINAGE-TUBES; GLOVES; SUTURES 
AND LIGATURES; SURGICAL APPLICATIONS 

Before going into the details of this chapter let 
us state here that gauze is the most commonly used 
material for sponges and dressings because of its great 
absorptive powers, its softness and pliability, and the 
ease with which it can be sterilized and handled. 

There are various grades on the market, each having a 
different mesh. The mesh varies according to the num- 
ber of fibers in a square inch. This fact is important, as 
will be seen later. 

Gauze Sponges. — Nearly every surgeon has his own 
particular size and pattern of sponge. Whatever size 
is decided on, be sure that there are no raw edges. They 
must be folded and invaginated in such a way that 
when ready for use no raveling or fiber is apparent, be- 
cause these little particles if left in a wound will prevent 
healing and may cause suppuration. Three sizes are 
generally used and should be of about a 14 by 20 mesh, 
so as to absorb easily: (a) Small or wide sponge for 
external use; (b) a larger sponge usually used wet for 
sponging in the abdominal cavity ; (c) a large gauze pack 
for use in keeping the intestines from the field of opera- 
tion. 

178 



ANTISEPTIC GAUZES, TAMPONS 1 79 

In operations on the brain small pledgets of cotton are 
most commonly used, and are usually moistened with 
normal salt solution. 

If marine sponges' are required for an operation, the 
dark-colored ones should be bought. They do not look 
so attractive, but they are the finest sponges; they are 
"uncut" and "unbleached," and give more service 
than the clearer-looking ones, which are partly or 
wholly bleached. The bleached and cheaper sponges 
have been made by cutting one large sponge into several 
small ones, or by cutting off portions that were torn in 
taking the sponges from the ocean. 

Marine sponges should be prepared as follows: I. 
Lay them in a stout cloth and pound sufficiently to break 
up grit and lime. 2. Rinse with warm water until it 
remains clear. 3. Immerse in hydrochloric acid solu- 
tion (2 drams to I quart of water) for twenty-four hours. 
4. Immerse in saturated solution of permanganate of 
potassium, followed with oxalic acid, then pass them 
through lime-water to take out all the oxalic acid, and 
rinse well in plain sterile water; after which they are 
immersed for twenty-four hours in a 1 : 1 000 corrosive 
sublimate solution. They are preserved until used in a 
3 per cent, carbolic acid solution. 

When wanted for use the sponges are lifted out of 
the jar with long dressing-forceps and rinsed in plain 
sterile water. 

Gauze pads for abdominal operations are made of 
eight thicknesses of gauze about 8 inches square, with 
the edges tucked in and hemmed to prevent fraying. 

Pads are usually made in sets of five, seven, or nine 
for purposes of identification. As a further precaution 



ISO SURGICAL TECHNIC 

to prevent a pad being left within the abdominal cavity 
they should have tapes attached. A weighted or gravity 
pad made by quilting flat bits of lead within the layers 
of gauze may be useful at times to act as a retractor of the 
intestines. 

Absorbent cotton used in dressing cases is prepared 
in the same way. 

Some hospitals find it expedient to sort, wash, re- 
sterilize, and use over soiled bandages and gauze. 
Cotton waste, after being boiled, sterilized, and dried, 
is used in place of absorbent cotton and gauze for the 
filling of pads. 

To sterilize oils or glycerin place in a water-bath 
and boil for fifteen minutes. 

Dressings. — The most common dressings are gauze, 
cotton-gauze, medicated gauze, and gauze packing. 

Gauze for dressings is usually of a 20 by 24 mesh. 
Ordinan- gauze dressing is about 24 to 36 ply and usually 
about 8 by 2 inches in size. The edges may be raw or 
folded in. 

Cotton-gauze Dressings. — These are used in connection 
with ordinary gauze dressings when considerable drain- 
age is expected. They are sometimes called cotton pads. 
They are made by covering an ordinary size strip of 
absorbent cotton with 2 -ply gauze with the edges of the 
latter folded in. They are usually packed in pairs with 
four pieces of ordinary gauze dressing and sterilized the 
proper length of time. 

Medicated Gauze. — The two principal forms of medi- 
cated gauze are: Sublimate gauze, which is gauze soaked 
in bichlorid of mercury solution of a definite strength and 
then dried. It is seldom used at the present time. 



ANTISEPTIC GAUZES, TAMPONS l8l 

Iodoform gauze is a sterile gauze soaked in a mixture of 
iodoform, ether, alcohol, and glycerin. The nurse 
should bear in mind that every step must be aseptic, 
because, once made, it should not be sterilized. 

1. Have the following ingredients at hand: 

Iodoform powder § vj; 

Glycerin Oj; 

Alcohol Sviij; 

Ether § viij. 

2. Sterilize the following: one basin, one spatula, and 
one pair of dressing forceps. 

3. Sterilize hands and don sterile gown and a pair of 
rubber gloves. 




Fig. 149. — Vaginal tampon, sterilized and placed in a gelatin capsule 
ready for use. (Hirst.) 

4. Carefully mix the iodoform powder and glycerin 
into a smooth paste in the basin with the spatula, then 
add the alcohol, and finally the ether. 

5. Now take the gauze, which has been cut into strips 
I yard long and 1 or 2 inches wide, and immerse slowly 
in the mixture. 



1 82 



SURGICAL TECHNIC 



6. Fold the gauze in layers in sterile test-tubes and 
cover with sterile cotton gauze plug. 




Fig. 150. — Cotton vaginal tampons. 

Tampons are made of absorbent cotton, lambs' wool, 
or gauze, and are about 7 inches long, ij inches wide, 



ANTISEPTIC GAUZES, TAMPONS 1 83 

and \ inch thick. They are folded and tied in the 
middle with a strong white thread or fine twine, leaving 
long ends by which to remove the tampon. The so- 
called kite-tail tampon is made by fastening several of 
these pieces of cotton to a thread about 2 inches apart. 
The tampons may, after sterilization, be kept in a dry, 
sterile jar or in wax paper. Tampons are principally 
used for introduction into the vagina. Previous to intro- 
duction they may be dipped into various special solutions. 
They are generally removed from the vagina on the day 
after the application. 

Collodion Dressing. — Collodion is a preparation of 
pyroxylin in alcohol and ether. On evaporation of the 
alcohol and ether a thin, impervious film of collodion is 
left. The collodion is either painted over the surface of 
the wound by means of a clean stick of wood or an ap- 
plicator with sterile cotton. A thin layer of absorbent 
cotton may be saturated with it, laid on the wound, and 
allowed to dry. Collodion is used only when the wound 
is aseptic. Various antiseptic agents, such as iodoform, 
boric acid, etc., may be dissolved or suspended in the 
collodion. The surface of the wound must be perfectly 
dry or the collodion will not adhere. An ordinary dry 
dressing may be applied over the collodion as a further 
protective. 

Gauze packing is made by cutting gauze in strips 2 yards 
long and 2, 4, and 6 inches wide. It is then folded so 
that there are no raw edges, and placed in layers in glass 
test-tubes. The tube mouth is closed with cotton over 
which is tied 2- or 3-ply gauze, and the whole sterilized in 
the autoclave. 

Other materials used for dressing purposes are: rubber 



I>4 SURGICAL TECHNIC 

dam. rubber mesh, and rubber tissue. They are used 
to protect dressings in cases of freely discharging wounds, 
in skin-grafting, and for drainage. Rubber dam is cut 
into various strips and applied in a criss-cross fashion to 
the wound area and over this is placed gauze. Rubber 
mesh is- sheet rubber dam with small perforations ar- 
ranged in rows. It is the best dressing for skin-graft 
cases because of its being one piece and. therefore, 
not liable to slip. Gauze is always placed over the 
rubber. 

Rubber tissue is sterilized in yV carbolic acid in cold 
water. Hot solutions will destroy it. 

Dressing-room Outfit. — Double wrapped packages 
containing the following articles are sterilized and kept 
in stock for use in the wards and private rooms: 

1. Package of cotton-ball sponges. 

2. Gauze dressings (usual size). 

3. Towels. 

Rubber-dam and drainage are kept in antiseptic solu- 
tion, and the instruments are sterilized as needed. 

Sheets, gowns, and towels used in operations are all 
made into convenient bundles and sterilized for two 
hours prior to an operation. Bundles once opened are 
not used again for other operations until they are re- 
sterilized. 

Emergency bundles containing everything necessary 
for an emergency operation are stored in cases provided 
for them; but if not used for forty-eight hours, are again 
sterilized before being used. 

Brushes. — Small hand brushes having a strong 
wooden back and stiff bristles are used for scrubbing 
the hands, field of operation, and the instruments. 



ANTISEPTIC GAUZES, TAMPONS 1 85 

They should be boiled for fifteen minutes before the opera- 
tion, then placed in a jar containing a 1 : 1000 corrosive 
sublimate solution. A separate brush should be reserved 
for the patient, and should be so marked. The same 
brush should never be used twice by the same person 
without being resterilized, and no two persons should 
use the same brush. 

Drainage. — The object of drainage is to carry off 
to the surface the secretions and discharges of wounds 
and cavities. The retention and accumulation of these 




Fig. 151. — Drainage-tubes and syringe for sucking them out. (Hirst.) 

would interfere with, healing and, in the case of septic 
discharge, involves the danger of general infection. 
Drainage may be secured by means of rubber or glass 
tubes, by strands of gauze, catgut, silkworm-gut, horse- 
hair, or silk. In case of abdominal section drainage- 
tubes are usually preferred to gauze drainage, because it 
gives freer drainage, does not require a large opening in 
the abdominal walls, and is tess likely to cause hernia; a 
sinus is more apt to follow the use of gauze drainage, 
and without anesthesia its removal is painful. Gauze 
soils the dressings and edges of the wound. The "ciga- 



:- 



?v? :-: :.,l :z:h:":: 



rette-drain" is made by rolling a loose twist of gauze in 
rubber iirr. 

The trrimir of postural drainage through the ab- 
domen, which has met with such good results, is very 




T\z ::: 



simple, and known as the Fowler position, which is in 
reality a sitting position for the patient. In this way 
the contents of the abdomen tend to drain to the 
lower portion. The lower abdomen seems to be much 
better able to take care of infection than the upper. 



ANTISEPTIC GAUZES, TAMPONS 1 87 

The Gatch bed is the best method of obtaining this 
position. 

Care of Drainage-tubes. — If a glass drainage-tube 
is in the abdomen, the care of it is usually left to the 
nurse. She must, each time before drainage, thoroughly 
scrub and sterilize her hands. A syringe is used to 
withdraw any fluid remaining and for injecting irri- 
gating solutions. The syringe must be sterilized by 
boiling and the nurse's hands disinfected. 

The rubber tube attached to the syringe is passed down 
the center of the drainage-tube to the bottom, then 
withdrawn a little, so that only the fluid will be drawn up, 
and not the tissue of the pelvis. The syringe-piston is 
to be slowly and steadily drawn up. When removing 
the syringe the nurse should be careful that blood does 
not drop on the dressing. The mouth of the tube is to 
be covered while the syringe is being emptied. 

Some surgeons place a piece of twisted gauze into 
the tube, which sucks up the fluid. This gauze is 
changed at stated intervals, and the tube is cleaned 
with a small piece of sterilized cotton or gauze fast- 
ened on the end of a pair of long forceps; then a fresh 
twist of gauze is inserted. The amount of fluid drawn 
and its character must always be reported by the nurse. 
When the drainage-tube is to be removed the nurse 
should observe the same precautions as she would for a 
dressing. 

Glass drainage-tubes are made aseptic by boiling 
for fifteen minutes before the operation. 

Preparation of Rubber Drainage-tubes. — Cut tubing 
into desired lengths, slip each piece over a glass rod, 
and scrub with a stiff brush and green soap. Rinse 



1 88 SURGICAL TECHNIC 

in sterile water until entirely free from soap. Boil for 
fifteen minutes in a I per cent, solution of sodium bicar- 
bonate (enough to impart a greasy feel to the water); 
rinse again several times in sterile water, and put into 
sterile jars and cover with carbolic acid, I : 20. The jar 
is kept covered except when the tubes are being put in 
and taken out by sterilized forceps. 

Rubber dam is sterilized by boiling in 1 per cent, soda 
solution, and is afterward transferred to a glass jar con- 
taining 1 : 20 carbolic acid solution. 




Fig. 153. — Drainage-tubes: a, Glass; b, rubber. 

Cargile membrane, tissue made from the peritoneum 
of the ox, is used as a protective against adhesion forma- 
tion, particularly in operations upon the bowels. 

Gloves. — Rubber and cotton gloves are much em- 
ployed in surgical work, and with very good results. 
They prevent infection by the surgeon's and assistant's 
hands, which even with the greatest care cannot be 
rendered completely sterile. The cotton gloves are 
sterilized by dry heat. The rubber gloves may be 
sterilized by the wet or the dry method. The wet 
method consists in boiling the gloves for fifteen minutes. 
In the dry method the gloves are dried, powdered with 
talcum, wrapped in towels, and placed in a pressure 
sterilizer, where they are allowed to remain for the length 
of time that dressings are sterilized. They are, however, 



ANTISEPTIC GAUZES, TAMPONS 



I89 



sterilized for only one day. In putting on the dry gloves 
the hands are first thoroughly dried and powdered. The 
advantage of the dry method is that the hand is not so 
liable to perspire, so that less bacteria is extruded in the 
event of the glove being punctured. Before putting on 
wet gloves they are distended with sterile water or a 
weak solution of bichlorid. Cotton gloves are frequently 
worn over the rubber gloves so as to protect them from 
injury, as in cases of bone operations, etc. 




Fig. 154. — Finger cots and rubber glove. 

Rubber-glove Solution. — Murphy suggests an asep- 
tic film covering sufficiently tenacious to last during 
several hours' work, to be made by dipping the hands 
and arms into a 4 per cent, solution of pure gutta- 
percha chips dissolved in sterile benzin or acetone 
(use chloroform or carbon tetrachlorid in place of these, 
owing to inflammability). The solution must not be 
boiled. Apply by immersion, allowing excess to drip 
from the fingers; the acetone solution dries in a few 
seconds, that of benzin requires two or three minutes. 
Remove from the skin, which is left pliant, by washing 
in benzin. 



I90 SURGICAL TECHNIC 

SUTURES AND LIGATURES 

A suture, as applied to surgery, is some material used 
for stitching. 

A ligature is some means used for tying. 

The materials used for sutures and ligatures are of two 
general types: Absorbable and non-absorbable. Among 
the former are catgut and kangaroo tendon, while among 
the latter may be classified silk, Pagenstecher, silkworm- 
gut, horse-hair, and wire. It will be seen from this that 
all animal sutures are not necessarily absorbable. A 
perfect suture or ligature must have the following 
qualities : 

1. Non-irritative to tissues.' 

2. Be capable of sterilization. 

3. Of sufficient tensile strength to accomplish the pur- 
pose for which it is used. 

4. Pliable, so that once tied it will remain so. 

5. Absorbable, so that if buried in the tissues it will not 
have to be removed. 

6. Durable, so that its longevity will be sufficient to 
accomplish the purposes for which it was intended. 

Catgut. — This material seems to fulfil all these pur- 
poses better than any other. It is obtained from the 
connective tissue of the sheep's intestine, preferably the 
European animal, as the quality of this gut seems to be 
of a higher standard. 

There is one fact that should always be borne in mind 
in its preparation. Catgut is dead animal tissue and, 
therefore, a good culture-media for bacteria; hence it 
must not only be sterilized, but made antiseptic. One 
of the simplest and best methods of sterilizing catgut is 
as follows: 



SUTURES AND LIGATURES 



191 



1. The strands are cut into convenient lengths, say 
30 inches, and rolled into coils about the size of a quarter. 
These are then strung on a thread so as to be easily 
handled. 

2. This string of catgut is now dried for four successive 
hours by hot air at the following temperatures, 160 F., 
200 F., and 220 F., the changes in temperature being 
gradually accomplished, and care being taken that the 
catgut does not touch metal or glass. 




Fig. 155. — Sterile catgut in glass tubes ready for use. 



3. It is then placed in liquid albolene until it is clear 
enough for strong light to pass through. It is usually 
left in this oil over night. 

4. The vessel containing the oil is placed upon a sand- 
bath and the temperature raised during one hour to 320 
F., which is maintained for a second hour. It is then 
placed in sterile jars or, if iodin catgut is desired, placed 
in the following: 

5. Iodin Catgut. — The thread is then lifted with a sterile 
forceps and the gut placed in a mixture of 1 part iodin 
crystals and 100 parts Columbian spirits (deodorized 
methyl alcohol). It is kept in this solution until used. 



112 SURGICAL 71 :z 

The above fluid prevents the catgut from softening, 
unraveling, and slipping when used. The iociin per- 
rr.r3.Zrrs -':.- ~zz3r.i zrz in 3 - ::: :i~e i: :e::~r-s z'.ick 
This is ir. intis-envi-: r:: 

Another simple but not reliable method is to place the 
catgut in iodin I part, potassium iodid I part, water ioo 
parts. Allow to remain eight day - 

Kangaroo tendon is obtained from the Australian 
animal, but is not used very much since the introdu : tic 
::" :z7:rr;::zrL :3zz~rz 

Chromicized Catgut — This is made by taking the 
above plain catgut from the oil, and instead of placing 
it in the iodin-alcohol it is placed in a solution of pot 
sium bichromate (15 grains to 1 pint of absolute alcohol). 

Both plain and chromicized catgut come in various 
sines 7. 3rr.tr/ :■:::: :-rri ;. 

The preparation of catgut has been minutely studied 
by commercial firms, so that the gut is always tested s 
its Eirenrnh :rz. i -z-rrrr/ v."i:h ;:.:: 3 z^r-riu' i±:'rr.i: 
it is better to employ one of the standard catguts. They 
are put up in glass tubes, jars, or paper folders. 

Silk. — It comes in various sizes, 00 to io, and ir. 
forms, white and iron dyed, the latter being black makes 
it more visible for removal. It is being used less as time 
goes on for the following reasons: It absorbs fluids into 
its meshes and thus becomes a favorable culture-medium 
for bacterial growth. Being non-absorbable it sooner or 
later becomes an irritant, and therefore should not be 
used in large - 5 as a buried ligature. It has been sup- 
planted in intestinal work by Pagenstecher thread. It is 
sterilized by boiling or in the autoclav 

Pagenstecher Material,- s linen tbi 



SUTURES AND LIGATURES 



193 



coated with celluloid which forms practically an imper- 
vious covering. Its tensile strength is greater than silk, 
so that a much finer thread can be used. It is exten- 
sively used in intestinal sutures. It is sterilized by boil- 
ing or in the autoclave. 

Silkworm-gut. — To obtain this 
material the silkworm is killed 
just about the time it is to spin 
its cocoon. It possesses a high 
tensile strength and is practically 
impervious to moisture. It var- 
ies somewhat in size. Some sur- 
geons use it entirely in closing 
the skin, while others employ it 
in vaginal operations because of 
its impermeability. It is easily 
sterilized by boiling. 

Horsehair is obtainea from 
the tail of the horse. It is im- 
permeable to moisture, the 
strands are very fine, and can 
be used with very small needles. 
It is of a fairly high tensile 
strength and more easily tied 
than silkworm-gut. It serves 
an excellent purpose in the 
cosmetic surgery of the face, 

neck, and mouth. It comes in hanks of one hundred 
strands and, after being thoroughly washed in soap 
and water, is sterilized by boiling. 

Wire. — There are three varieties used: Aluminum- 
bronze, silver, and gold, in the order of their usefulness. 
13 



Fig. 1 56 j — Silk in glass 
tube on glass reels; the 
tube is stoppered with cot- 
ton. (Hirst.) 



194 SURGICAL TECHNIC 

Their sphere is very limited, being at the present time 
used chiefly to approximate fragments of bone. Silver 
wire is used as a skin suture. 

The wire must have a fairly good tensile strength and 
be sufficiently flexible to be twisted without breaking, 
The aluminum-bronze wire possesses these to a greater 
extent than the softer metals. 

Michel's clamps consist of modified metal clamps which 
are applied to the skin by a special holder. After the 
wound is healed they are removed by a special instru- 
ment. The advantages claimed for them are that they 
are quickly applied and are less liable to cause infection. 

Surgical Applications. — They comprise ointments, 
pastes, etc., which are used in the treatment of local 
surgical conditions. 

Ichihyol. — This is a brownish-black semiliquid prep- 
aration with a strong penetrating odor of tar. It is 
mildly anesthetic and analgesic and slightly counter- 
irritant. It also has to a certain extent the action of a 
poultice when used in treatment of abscesses before 
incision. 

It is not often used pure. From 10 to 25 per cent, 
ointment is the most common strength used. 

Balsam of Peru. — This is a semi-liquid vegetable prod- 
uct. Has a pleasant odor. It is a deodorant and mildly 
stimulating to granulating tissues. 

Beck's Bismuth Paste. — This is used for diagnostic 
purposes and treatment of chronic discharging tissues. 
The formula is as follows: 

Bismuth subnitrate 3^ per cent. 

White or yellow vaselin 66| " 



SUTURES AND LIGATURES 1 95 

The vaselin is sterilized and while liquid the bismuth 
is stirred into it. When used it is melted and sucked up 
into a glass or specially made metal syringe and injected 
into the discharging sinus. Care must be taken to keep 
water away from it. For this reason the syringe is dry 
sterilized, and if the piston needs lubrication, oil is used 
instead of water. Always use a blunt-pointed syringe. 

Occasionally a paste of firmer consistency is used. 
This is composed of: 

Bismuth subnitrate 30 per cent. 

Paraffin 5 " 

White wax 5 

White or yellow vaselin 60 

Mosetig-Moorhof wax is a combination for the filling in 
of infected bone cavities. It is composed of: 

Iodoform 60 parts. 

Spermaceti 40 " 

Oil of sesame 40 " 

Heat to ioo° C. and then allow to cool. When needed, 
heat to 50 C, constantly stirring, so as to thoroughly 
distribute the iodoform. It is poured into the bone- 
cavity which has previously been made aseptically clean 
and dry. It becomes absorbed the same as a bone-graft 
and new bone grows into the cavity. 
Unna's paste is made up of : 

Gelatin 5 parts. 

Zinc oxid 5 " 

Boric acid 1 part. 

Glycerin 8 parts. 

Water 6 " 



I96 SURGICAL TECHNIC 

It is heated until it becomes a soft liquid paste. The 
principal use of it is as a supporting and antiseptic dressing 
for varicose leg ulcers. When liquid the paste is applied 
with a brush over the whole surface of the leg, including 
the ulcer, then a layer of gauze bandage applied; then 
more paste and another layer of bandage, and so on until 
three or four layers are applied. Depending on the 
amount of discharge, this dressing is allowed to remain on 
for from two days to a week. 

Hors}ey's wax is used to stop hemorrhage from bleeding 
bone. It consists of: 

Beeswax 7 parts. 

Almond oil 1 part. 

Salicylic acid 1 " 

Green Soap. — 

Caustic potash 13 ounces. 

Linseed oil 40 " 

Alcohol 4 " 

Heat the oil in a vessel to 140 F. Dissolve the potash 
in 67 ounces of hot water. Add the alcohol and let it 
cool. Then add the heated oil, stirring constantly until 
mixed. 

To make a tincture of green soap: 

Green soap 3 parts. 

Alcohol, 95 per cent 2 " 

Ether 1 part. 

To prepare cold, mix and stir for a few minutes every 
hour until a clear solution is formed, or the soap may be 
melted first over a slow fire. Remove to a safe cool place, 
stir occasionally, and just before complete hardening 
recurs add the alcohol and ether. 



CHAPTER X 

INFLAMMATION 

Inflammation is the reaction of a part to an irritant. 

The first changes are in the vessels and circulation; 
second, a passing out of fluids and solids from the 
vessels; and third, changes in the perivascular tissue 
— i. e. } the tissues about the blood-vessels. These 





Fig. 157. — Normal vessels and Fig. 158. — Dilatation of the vessels 

blood-stream. in inflammation. 

(American Text-Book of Surgery.) 

three changes produce the characteristic phenomena 
of inflammation — heat, redness, swelling, pain, and 
loss of function. 

The first change in an inflamed area is a dilatation 
of all the vessels — the arterioles, capillaries, and venules. 
As a result there is an increased activity in the circu- 

197 



198 



SURGICAL TECHNIC 



lation and an increased flow of blood to the part, a con- 
dition known as active hyperemia. After a time the 
blood-current begins to slacken; then the white cells 
approach the vessel wall and begin to pass through it 
(emigration of white cells). There is also a passing out 
of plasma or fluid from the blood, and in severe cases 
of inflammation the red cells may also pass out. If we 
now examine the inflamed area with a microscope we 




Fig. 159. — Ice-bag (Ashton). 



Fig. 160. — Water coil. 



find an enormous number of cells, chiefly white blood- 
cells, in the tissues about the vessels. Fibrin in the form 
of delicate granules and fibrils may also be present. 

Inflammation is a process which is directed to the re- 
moval of an irritant, which may be either a portion of 
an injured tissue or a foreign body or material. After 
this result has been accomplished, healing or regen- 
eration takes place. If the inflammation was caused 
by bacteria, suppuration is likely to follow. In that 



INFLAMMATION 1 99 

case the tissues will liquefy and the cells will be thrown 
off suspended in a liquid (liquor puris), the whole being 
known as pus. In suppuration there is always loss of 
tissue, and healing, if it occurs, is brought about through 
the formation of a scar. In order to produce healing 
granulation tissue is formed. Granulation tissue consists 
of new cells and tiny capillary loops. It is sometimes 
called "proud flesh," and bleeds very easily. The scar 
has a marked tendency to contract and may cause great 
deformity. 

Among the causes of inflammation are injuries, chem- 
ical irritants, heat and cold, and bacteria. 



CHAPTER XI 

CATHETERIZATION ; DOUCHES ; ENEMATA ; 
WASHING OUT THE BLADDER; LAVAGE 

The use of the catheter is ordinarily very simple, 
and yet it may truthfully be said that there is no opera- 
tion which is performed with so little regard for asepsis. 
Asepsis and antisepsis are as important here as they 
would be in preparing for an abdominal operation. 

Cystitis is often caused by the introduction of germs 
into the bladder by means of a dirty catheter, or by 
not cleansing the external genitals, vestibule, and 
meatus before the operation. Normal urine is to be 
considered sterile unless there is some disease of the kid- 
neys or bladder; and when infection occurs we may 
assume that the germs have gained entrance from with- 
out. The catheter may be of glass. When a glass cath- 
eter is not at hand, a silver or rubber one may be used. 
When of glass or silver or rubber it should be boiled 
twenty minutes before being used. 

Glass catheters are the best; they are easily rendered 
aseptic, and show whether they are or are not perfectly 
clean. Sterilization is most important before using the 
catheter and immediately afterward. There is no danger 
of the catheter breaking, as so many patients fear, if it is 
not cracked before being introduced. Besides the cath- 
eter, which is taken to the bedside in a basin of very hot 
water, there are needed a basin of corrosive sublimate 



catheterization; douches; enemata 



20I 



solution (i : iooo), sterilized gauze or cotton, and a vessel 
to receive the urine. A lubricant of sterilized oil to 
render the entrance of the instrument as easy as possible 
is used only when a gum-elastic or rubber catheter is 




Fig. 161. — Virginal vulva: i, Labia majora; 2, fourchet; 3, labia 
minora; 4, glans clitoridis; 5, meatus urinarius; 6, vestibule; 7, entrance 
to the vagina; 8, hymen; 9, orifice of Bartholin's gland; 10, anterior com- 
missure of labia majora; 11, anus; 12, blind recess; 13, fossa navicularis; 
14, body of clitoris. (Modified from Tarnier.) 



employed. A mixture of carbolic acid solution (1 : 40) 
and glycerin serves for this purpose. 

Introduction of the Catheter. — The patient lies on 
her back with the knees drawn up and separated, the 
upper clothing being divided over each knee to guard 



202 SURGICAL TECHNIC 

against unnecessary exposure. The labia are separated 
with sterilized sponges and the parts washed with the 
corrosive solution. The catheter is inserted into the 
urethra, the opening of which is just above the vaginal 
entrance. If there is any difficulty, the catheter should 
be withdrawn a little and gently pointed a little down- 
ward or upward, to the right or to the left. If the flow 
should cease before enough urine has been drawn, the 
catheter is withdrawn a little or is inserted a little farther 
than before. Before removing the catheter a finger should 
be placed over its end to prevent any drops of urine 
wetting the bed. After the operation the parts are again 
washed, and the catheter boiled and placed in a bottle 
containing a solution of carbolic acid (i : 20), unless the 
catheter is of rubber, for carbolic acid ruins rubber. 

When the bladder is partially paralyzed from result 
of an operation or otherwise, a rectal injection of very 
warm water will often cause the bowel and bladder to 
empty themselves at the same time, thus doing away with 
the necessity of using a catheter.. 

The urine for examination by the physician is best 
drawn with the catheter, to prevent contamination from 
vaginal discharges. 

A distended bladder must be emptied gradually; 
several sittings, at intervals of four to six hours, may be 
necessary in some cases, and as the last amount of urine 
is being drawn the flow should be slowed, to prevent any 
injury to the mucous membrane of the bladder from draw- 
ing it into the eye of the catheter. 

Irrigation of the Bladder. — To irrigate the bladder a 
fountain-syringe or irrigating apparatus is cleansed by 
boiling; also a glass catheter, which is sterilized in the 



catheterization: douches: enemata 



203 



same way as for catheterizing. The parts, of course, are 
cleansed in the manner described. The patient is first 




Fig. 162. — Showing the method of irrigating the bladder by the single- 
catheter method. (Morrow.) 



catheterized ; the catheter is then attached to the rubber 
tubing of the syringe which contains the irrigation solu- 
tion (boric acid or salt solution), the temperature of the 



204 



SURGICAL TECHNIC 



latter being about ioo° F. The solution must run warm 
before the catheter is inserted. The rapidity of the flow 
is regulated by raising or lowering the irrigator. The 




Fig. 163. — Irrigation of the bladder with a double-flow catheter. 
(Morrow.) 



quantity of solution introduced is governed by the feelings 
of the patient; usually 200 c.c. is all that can be tolerated, 
after which the tube is disconnected and the fluid is 



catheterization; douches; enemata 



205 



drawn off. If a double catheter is used, the tubing is 
not removed. The irrigation is repeated until the wash- 
ings come away perfectly clear and clean. 

Examination of Stomach Contents. — Many times the 
nurse is called upon to give a test-breakfast and to send 
the stomach contents to the laboratory for examination. 




Fig. 164. — Position of the pa- 
tient for introduction of stomach- 
tube; also method of passing tube 
into the mouth. (Boston.) 



Fig. 165. — Method of inducing 
expulsion of gastric contents by 
siphonage. (Boston.) 



A test-breakfast usually consists of a cup of tea with- 
out milk or sugar and two soda-crackers, or instead of the 
crackers a small piece of toast or small piece of bread 
without butter is given. One hour after the stomach 
contents are obtained by passing the stomach-tube. 

Method of Passing a Stomach-tube. — The stomach-tube 
should be used from ice-water, with the patient, covered 



206 



SURGICAL TECHNIC 



with a sheet, sitting in a chair. He should be advised 
that the procedure will be unpleasant but is not danger- 
ous, and that he must not under any circumstances 
pull your hand away or bite the tube, but at all times 
must swallow. Have the patient extend the head and 
open the mouth, then introduce the cold stomach- 
tube into the throat through the mouth, at the same 




Fig. 1 66. — Stomach-tube and funnel for expressing the stomach con- 
tents: a, Showing the lateral fenestra; b, funnel; c, mark to indicate the 
distance from the incisor teeth to the stomach. (Morrow's Diagnostic 
and Therapeutic Technic.) 



time asking the patient to swallow; rapidly push the 
tube down, provided that there is no obstruction, 
until you come to the white mark on the tube; then 
lower the bulbous end of the tube to drain the stom- 
ach by siphonage. On some stomach-tubes there is a 
bulb to assist the siphonage; in others you will have to 
compress the tube near the mouth and draw the fingers 
of the other hand toward the exterior extremity of the 



catheterization; douches; enemata 207 

tube. Suddenly remove the fingers near the mouth and 
it will produce a small degree of suction. It may be 
necessary to introduce a small amount of water to start 
siphonage. Elevate the funnel portion higher than the 
mouth and then suddenly drop the funnel portion, in this 
way producing a siphonage. At times it may be neces- 
sary to introduce the tube a little farther down the 
throat. Vomiting may occur, in which event it will be 
necessary to repeat the entire performance. If water 
has been necessary to assist in the siphonage, this fact 
should be noted in the report. In very nervous patients 
it is advisable to cocainize the throat. 

The contents are measured and placed in a clean 
bottle, labeled with the patient's name, the date, 
quantity, and hour that the breakfast was given and 
contents secured; the bottle is then sent immediately 
to the laboratory. 

Gastric lavage consists in introducing the stomach- 
tube and allowing a pint or two of warm water to run 
into the stomach, and then by quickly dropping the fun- 
nel portion of the tube, removing the same by siphonage. 
This should be continued until the fluid comes away 
clear. 

Douches. — Properly given, the vaginal douche relieves 
inflammation, checks hemorrhage, acts as a stimulant, 
cleansing agent, and checks secretion. The amount 
of water used is from 5 to 6 quarts, of a temperature of 
no° F. The temperature must always be tested with a 
bath-thermometer (Fig. 167), not with the hand. The 
douche apparatus is an excellent contrivance. In its 
absence a fountain-syringe may be used. 

When taking a douche the patient should lie on her 



2oS 



SURGICAL TECHNiC 




back, with the thighs flexed on the abdomen and the 
legs flexed on the thighs. In this position the water comes 
in contact with the whole vagina. 

The douche can or fountain-syringe must be hung 
about 4 feet above the bed, so that it will take about 
twenty minutes for the water to run 
out. Air must be expelled, and the 
water must run warm before the tube is 
inserted into the vagina. The vaginal 
tube must always be sterilized before 
and after using, and every patient 
should have her own tube. 

Many patients in private practice ob- 
ject to taking douches, and will neglect 
them on account of the inconvenience; 
but this they can overcome by taking 
the douches in the bath-tub. Half-way 
across the bottom of the tub a piece of 
board is placed on which the patient can 
lie. 

Antiseptic Douches. — Corrosive sub- 
limate, creolin, boric acid, and perman- 
ganate of potassium are used for anti- 
septic douches ; and to prevent absorption 
and irritation a plain water douche is 
often given after any of these antiseptics. 
After any intra-uterine douche too forcibly given uter- 
ine colic with dangerous collapse may occur. 

A patient should lie quietly for one hour after tak- 
ing a douche; if only one is used a day, it is best to 
give it at night, because then the uterus is most con- 
gested and needs the hot water most, and the tempo- 



Fig. 167.— Bath- 
thermometer. 



catheterization; douches; enemata 



209 



rary weak feeling which follows a douche will be gone 
before morning. 




Fig. 168. — Apparatus for vaginal douching. (Morrow.,; 

Rectal Injections (Enteroclysis) and Irrigation. — 

The therapeutic range of this procedure is not confined 
to the treatment of local troubles. It has long been used 




Fig. 169. — Enlarged view of a glass vaginal douche nozzle. (Morrow.) 



as a means of cleansing the lower bowel of accumulated 
feces. In the treatment of rectal ulcers and inflam- 
mations it has been employed both to relieve the irrita- 

14 



2IO 



SURGICAL TECHNIC 



tion produced by fecal matter and to apply various 

medicaments to the parts. For the prevention of shock 
normal saline solution is injected — 
i or 2 pints. This, by filling the 
blood-vessels, enables the patient 
to withstand the loss of blood. 
After an operation shock and 
hemorrhage are counteracted by 
its use, and at the same time the 
thirst is relieved and restlessness 
quieted. In septic conditions, both 
local and general, by diluting the 
toxic materials in the circulation 
and promoting their excretion by 
the skin, kidneys, and bowels, 
saline rectal injections play an im- 
portant part in the treatment. 

Dr. John B. Murphy has devised 
a method whereby salt solution, 
if given by the drop method, it is 
possible to have the patient re- 
ceive a continuous supply of this 
solution. There are numerous ap- 
paratus, the simplest of which con- 
sists of a douche bag and tubing 
held in place about 2 feet above 
the bed. The tubing is connected 
to a specialized dropper as shown in 
the diagram. A clamp placed im- 
mediately above regulates the flow. 

The temperature of the solution is usually about 105 F. 

Many procedures have been devised to keep the water 



Fig. 170. — Modifica- 
tion of Dewitt's appli- 
ance for regulating flow, 
and allowing escape of 
flatus. (Crandon and 
Ehrenfried.) 



catheterization; douches; enemata 



211 



at an even temperature. The simplest method of noting 
the desired temperature is to have the tube run under a 
hot-water bottle placed at the side of the bed. 

In patients whose digestive tracts are too weak to hold 
food or medicine rectal feeding or rectal medication is 




Fig. 171. 



-A very simple apparatus for continuous proctoclysis, 
row.) 



(Mor- 



employed. The rectum should be washed out thoroughly 
before the injection is given. If the rectum is intolerant 
and will not retain what is injected, it is well to turn the 
patient on her left side and raise the hips on a pillow or a 
folded blanket. A long rectal tube should be used as for 
a high enema. The physician will give directions as to 



212 



SURGICAL TECHNIC 



the temperature of the solution. In fever patients and 
in the hemorrhage of typhoid fever great relief and com- 
fort are afforded by using very cold or iced water. In 
shock or hemorrhage a temperature of ioo° F. is usually 
preferable. In long-continued lavage for local trouble 
the patient's preference as to the temperature is gener- 
ally consulted. 




Fig. 172. — Showing the method of administering continuous procto- 
clysis: a, Adhesive strap fastening the tubing to the thigh; b, vaginal noz- 
zle bent at an angle of 35 degrees. (Kelly and Noble.) 

A stimulating and nutrient enema, black coffee, or 
hot saline solution is given when symptoms of shock 
appear either during or after an operation; it should be 
injected high up into the colon. The rectum should be 
thoroughly cleansed at least once daily with warm 
saline solution, which will also aid the absorption of the 
nutrient enema. When feeding by rectum in gyneco- 



catheterization; douches; enemata 



213 



logic cases, it should be remembered that tight tampon- 
ing of the vagina may interfere with absorption in the 
rectum. If the presence of hemorrhoids is a drawback, a 




Fig. 173. — Funnel and colon tube for administering nutrient enemata. 

2 per cent, solution of cocain may be used before injecting 
the fluid. 



Stimulating enema: 
Whisky, 

Ammonium carbonate, 
Beef-tea, 



Or, 



Brandy, 

Tincture of digitalis, 

Milk, 



2 ounces. 

15 grains. 

4 ounces. 

2 ounces. 

20 minims. 

4 ounces. 



214 



SURGICAL TECHNIC 



For tympanites: 





1 mcture ot asatetida, 




2 ounces. 




Spirits of turpentine, 




i ounce. 




Magnesium sulphate (Ep- 






som salt), 




2 ounces. 




Warm water, 




I pint. 


Purgative enemata: 






I. 


Warm soap-suds 




i pint. 


2. 


Glycerin, 




4 ounces. 




Magnesium sulphate, 




I ounce. 




Spirits of turpentine, 




I ounce. 




Warm soap-suds, 




8 ounces. 


3- 


Glycerin, 




4 ounces. 




Turpentine, 




I ounce. 




Magnesium sulphate 


(Ep- 






som salt), 




2 ounces. 


5- 


Inspissated ox-gall, 




| ounce. 




Warm water, 




I quart. 


5- 


Spirits of turpentine, 




io drops. 




Mucilage of acacia, 




J ounce. 


To be given high. 






6. 


Senna, 




\ ounce. 




Magnesium sulphate, 




\ ounce. 




Olive oil, 




I ounce. 




Boiling water, 




I pint. 


Infuse the senna in the water. 


Then dissolve the 


magnesia, add the oil, and 


thoroughly mix by stir- 


ring. 







CHAPTER XII 

MINOR SURGICAL PROCEDURES 

Hypodermic Injection. — This procedure is employed 
to secure rapid medication or in obtaining local anes- 
thesia by the injection method. When used in the 
latter capacity it is called intradermic injection. 

The aseptic method of employment requires that 
the syringe, needle, and solution should be sterile. To 
cleanse the skin about the point of intended puncture 



Fig. 1 74. — Showing the method of giving a hypodermic injection. (Mor- 
row.) 

use first soap and water. Apply ether, alcohol, or tinc- 
ture of iodin to render the site sterile. 

Insert the needle-point at the summit of a pinched- 
up fold of the sterilized skin (Fig. 1 74) . For hypodermic 
medication the skin of the arm, forearm, or the thigh 
may be selected, fleshy parts favoring rapid absorption. 
Avoid superficial veins and deeper vessels, as direct 
entry of the drug into the blood-current might give rise 
to a too rapid effect. 

21S 



216 



SURGICAL TECHNIC 



Sutures. — The interrupted suture is made by passing 
catgut or silk through the skin from one side of the wound 
to the other ; then both ends are drawn together and tied 
in a double knot. The continuous suture is the ordinary 
over-and-over stitch from one end of the wound to the 




"<«& 



2258 



Fig. 175. — Interrupted suture. 
(Bernard and Huette.) 



Fig. 176. — Continued or Glover' 
suture. (Bernard and Huette.) 



other. The button suture is made by passing a double 
stitch across the bottom of the wound, bringing out the 
ends about 1 inch from the edge of the wound and secure 
each end by passing through a button. The shotted 
suture is one in which the ends of the suture, after it is 





Fig. 177. — Button suture, 
ant.) 



(Bry- Fig. 178. — Metal suturing clamps. 



introduced, are passed through a perforated shot, which 
is then clamped. 

Counterirritation or revulsion is a method of pro- 
ducing artificial irritation upon one portion of the body 
surface to alter the progress of disease in distant parts. 
It acts directly by drawing blood away from the diseased 



MINOR SURGICAL PROCEDURES 217 

area or through the nervous system, and may be used in 
cases of localized inflammation or congestion to over- 
come neuralgic pain and in conditions of general depres- 
sion or shock. 

The methods employed may be mild or severe in their 
effects. Of the milder means used for the purpose, the 
mustard foot-bath is one of the best. It consists in soak- 
ing the feet and legs of the patient in a bucket two-thirds 
full of water at a temperature of from no° to 140 F., 
to which has been added one to two tablespoonfuls of 
ground mustard. The patient's body should be pro- 
tected by blanketing during the bath, which may con- 
tinue for from ten to twenty minutes. Tincture of iodin 
is used for a similar purpose in chronic inflammation of 
joints or glands. It may be applied with a swab or 
brush to the parts. Application must not be made 
oftener than once in two to four days to patients having 
tender skins. 

Mustard-plaster, made by mixing up 1 part of ground 
black mustard to 5 parts »of wheat flour or flaxseed 
in a little water, and applied upon a cloth or folded news- 
paper to the parts, will often prove useful in widespread 
inflammation or irritations. A fresh mustard-plaster 
should not be .applied for a longer period than twenty or 
thirty minutes, else it may give rise to local injury to the 
skin and directly underlying tissues. 

Turpentine Stupe. — This method of producing counter- 
irritation consists in the application to the inflamed 
parts of a flannel cloth which has been wrung out in 
hot water and sprinkled or dipped and wrung out in 
either the spirits or oil of turpentine. The skin should 
be anointed with vaselin if the application causes too 



2l8 SURGICAL TECHXIC 

much pain or irritation. Spice-plasters or bags are often 
ordered in the treatment of children. The mixture 
consists of equal parts of ground ginger, cloves, cinna- 
mon, allspice, to which add and thoroughly mix one- 
fourth part of Cayenne pepper; wet with hot water, alco- 
hol, or whisky before applying. The so-called warming 
plaster consists of Burgundy pitch 12 parts, cantharides 
cerate 1 part. 

Heat and cold are identical in effects. 
Use. — (1) Locally as a stimulant (if of moderate 
intensity and applied but for a short time and if fol- 
lowed by immediate reaction) ; also as a sedative (if 
of long application, very intense, and if no reaction 
occurs). (2) Constitutional: (a) Heat may be used as 
a pyretic in shock, collapse, insanity; (b) cold as an anti- 
pyretic in acute fever, sunstroke. 

Application. — (1) Heat. — (a) Dry (in the form of 
hot-water bags or bottles, hot bricks, hot sand or salt 
bags, heated stovelids. hot-air-oven apparatus, hot 
blankets); (b) Moist, poultice ( flaxseed, oatmeal, or 
hops, mixed with water, is sterilized by boiling) ; hot 
bath; hot pack; hot douche; hot fomentation (gauze, 
flannel, or towel wrung out in hot water, hot antiseptic 
solution; change when cooled). A ready method of pro- 
ducing diaphoresis (sweating) is by pouring water upon 
hot bricks wrapped in flannel. 

(2) Cold. — (a) Dry (applied in the form of crushed 
ice in thin rubber bags, bladders, ice water passed 
through coils of rubber tubing) ; cold air (by expos- 
ure) ; (b) Moist (irrigation, ice-water compresses, cold 
pack — wringing sheet out in ice water and wrapping 
it around the patient; keep it wet by sprinkling); 



MINOR SURGICAL PROCEDURES 219 

tepid bath (gradually reduced) ; sponge-bath (keep the 
patient's body surface moist, fanning him all the time) ; 
alternating douche of hot and of cold water. 

Vaccination is the inoculation of an individual with 
the virus of cow-pox. 

The implements needed are a needle, lancet, or ivory 
point ; fresh virus (bovine or humanized) . 

Vaccination is performed as follows: (a) Render 
skin surface aseptic (select by choice upper and outer 
third of arm, inner side of thigh); (b) abrade the skin 
until serum exudes; (c) carefully work in the moistened 
virus; (d) protect surface of spot until dry. Avoid 
exposure. 

The times to perform vaccination are: (1) About 
the third month; (2) seventh year; (3) at puberty; (4) 
repeat whenever small-pox is prevalent. 

Liniments.- — These are local stimulants useful in 
mild neuralgic or rheumatic pains: (a) Ammonia; 
(b) chloroform; (c) camphor; (d) turpentine. Apply 
upon a cloth or by rubbing into the parts for a period 
of from five to twenty minutes; anoint with vaselin 
after each application to prevent abrasion. 

Ointments. — Mildly stimulating and emollient: (a) 
Mercurial (blue ointment); (b) ichthyol; (c) bella- 
donna; (d) boric acid; (e) resorcin; (/) iodin. Do not 
use iodin locally where there will be a possibility of a 
future cutting operation, because the skin becomes like 
leather and heals badly. 

Ointments should be applied upon gauze or lint, 
nicked to allow for the escape of discharge if present. 

Cupping. — 1. Dry Cups. — In dry cupping no blood 
is lost. The operation is performed by means of special 



220 



SURGICAL TECHNIC 



cupping-glasses or wineglasses. Exhaust the air by 
burning a little roll of paper, piece of lint, or paper dipped 
in alcohol and lighted. Before the flame is extinguished 
rapidly invert the glass upon the skin surface. 

2. Wet Cups. — (a) Prepare the skin by cleansing 
with soap and water, dry thoroughly, and apply dry 
cups ; (b) scarify with a bistoury or by means of a spring 
scarificator upon the cupped sites; (c) reapply the cups 




Fig. 179. — Instruments for wet cupping: 1, Cupping glasses; 2, swab in 
alcohol; 3, alcohol lamp; 4, scalpel. (Morrow.) 



to the incised areas; (d) treat the scarification wounds 
antiseptically. 

Cupping is employed to produce local depletion; wet 
cups are better in serous inflammations. 

Leeching. — (a) American leech (draws about a tea- 
spoonful — 4 c.c. — of blood). 

(b) Swedish leech (draws three or four — 12 or 16 c.c. — 
teaspoonfuls). 



MINOR SURGICAL PROCEDURES 221 

A mechanical leech consists of a scarifier, cup, and 
exhausting air-pump attachment. 

Method. — Prepare the skin surface by cleansing with 
soap and water; dry thoroughly; apply the leech to the 
area moistened with blood or milk; confine the leech 
to the moistened area by means of an inverted glass 
tumbler. To remove the leech sprinkle a little salt upon 
its head. To preserve the life of the leech, strip it of the 
sucked blood and replace in a jar of water having a per- 
forated cork. Dress the wound antiseptically, apply a 
compress, nitrate of silver torsion, acupressure for con- 
tinuous bleeding. 

Leeching is employed to secure local depletion. 

Venesection. — This procedure is performed to relieve 
tension in elevated blood-pressure, such as in acute kid- 
ney disease, pneumonia, and pulmonary edema. 

The simplest method is to insert a large caliber needle 
directly into the vein after the venous circulation has 
been dammed back by a tourniquet. Frequently it is 
necessary to expose and incise a vein. For this proceed- 
ing the following instruments are necessary: Small scal- 
pel, scissors, plain and tooth tissue forceps, small retrac- 
tors, needles, sutures, and ligatures. 

Under local anesthesia a small skin incision is made over 
the vein which is exposed and dissected free. A double 
ligature is then passed under the vein. The upper one is 
tied and the lower one is left loose. A small opening is 
then made in the vein between the two ligatures and the 
blood caught in a basin. When enough has been taken, 
the lower ligature is tied and the skin wound sutured 
and a dressing applied. 

Intravenous Infusion. — This is the best treatment to 



222 



SURGICAL TECHNIC 



combat traumatic and surgical shock, and is used after 
a severe hemorrhage. The same instruments are used as 
for a venous section, and, in addition, an irrigating can, 
rubber tubing, and an infusion needle are necessary. 
These must all be sterilized. One quart of normal salt 
solution is the usual fluid used. 
In severe shock a dram of adre- 
nalin chlorid solution is added. 
At times it is possible to use a 
sharp-pointed needle for this 
procedure, and plunge it directly 
into the vein without incising 
the skin. (See Venesection.) 




Fig. 1 80. — Giving hypodermoclysis under the left breast. (Ash ton.) 



Hypodermoclysis. — This is another method of giving 
salt solution in cases of shock and hemorrhage. A sharp- 
pointed large caliber needle is attached to an irrigating 
can by rubber tubing. The needle is usually plunged 
under the breast near the chest wall, the skin being 
first thoroughly disinfected and the can held about 3 to 4 
feet above the patient while the solution is being run in. 



MINOR SURGICAL PROCEDURES 



223 



The breast is massaged so as to quicken the absorption of 
the fluid. Every nurse should be able to prepare and 
give hypodermoclysis. 




Fig. 181. — Bier's vacuum treatment apparatus for boils. 

Bier's Hyperemia.— This treatment has for its prin- 
ciple the increase of blood to the part, which therefore 
increases the number of leukocytes. It is used in infected 
areas. The principle is the same as cupping, in that a 




Fig. 182. — Bier's air suction apparatus for treating stiff knee. 



vacuum is formed, but it is not as mild. Special appara- 
tus is needed. It may be obtained in the extremities by 
placing a tourniquet around the arm or thigh sufficiently 
tight to particularly obstruct the venous return. 



224 SURGICAL TECHNIC 

Normal saline solution is made to correspond as 
nearly as possible with the normal serum of the blood. 
It contains calcium chlorid 0.25 gm., potassium chlorid 
0.1 gm., sodium chlorid 9 gm. to 1 quart of distilled 
water. It not only gives the heart a better fluid to 
work upon, but it restores to the blood that coagulable 
quality which is diminished or lost by hemorrhage. 




Fig. 183. — Intravenous saline infusion. Manner of incising vein and 
inserting glass tube. (Senn.) 

Tablets containing this formula have been devised, and 
are usually used. One tablet added to 1 quart of water 
gives the correct strength. In the absence of the tablets 
1 teaspoonful of table salt is added to 1 pint of water. 
It is absolutely necessary, whatever formula is used, that 
the solution and all the apparatus used should be properly 
sterilized. If the water contains particles that cannot 



MINOR SURGICAL PROCEDURES 



225 



be strained out and there is no filter at hand, the water 
should stand until the sediment settles, when the fluid 

can be poured off, resteril- 
ized, and used. This solu- 
tion is placed in an irri- 
gator or a fountain-syringe 




Jinai 



Fig. 184. — Apparatus for hypo- 
dermoclysrs. (Hirst.) 



Fig. 185. — Improvised appar- 
atus for the irrigation of a 
wound. (Da Costa.) 



tempera- 



which has been thoroughly sterilized. The 
ture of the solution should be about no° F. 

In hospitals it is customary to keep on hand flasks of 
is 



226 



SURGICAL TECHXIC 



saline solution. These flasks are sterilized before filling, 
afterward they are stoppered with sterile cotton plugs 
and sterilized again by boiling for one hour on three suc- 
cessive days. 

Normal salt solution is used for irrigation and for in- 
jections in cases of shock, in acute diabetic and uremic 
coma, hemorrhage, puerperal infection, and eclampsia. 




Fig. 1 86. — Apparatus for douching the abdominal cavity. (Hirst.) 



Scarification. — This consists in the making of small 
linear incisions through the skin and subcutaneous or 
mucous tissues for the purpose of securing depletion to 
relieve tension. 

Puncturation is the operation of making punctures 
with a sharp-pointed bistoury through the skin or mucous 
tissues. It is performed to secure local depletion or to 
relieve pressure. 



MINOR SURGICAL PROCEDURES 227 

Incision of Abscess for Drainage. — The nurse should 
have sterilized knife, scissors, hemostats, and tissue for- 
ceps. Rubber dam and tubing for drainage, gauze dress- 
ing, bandages, and pus basin. Some use disinfecting solu- 
tions, such as iodin, Harrington's, and bichlorid. These 
should be at hand, as should also cotton sponges. 

Hot-air or Baking Treatment. — This treatment is 
used for acute and chronic conditions of joints and for 
tenosynovitis, sprains, effusions, and fractures. 

The part must be protected with blankets or flannel 
bandages, the temperature at which it is used varies from 
ioo° to 200° F. There are special bakers or types of 
apparatus on the market for this treatment 

Deep puncture and incision with a sharp-pointed 
bistoury is sometimes performed — (a) To relieve ten- 
sion; (b) to secure drainage. 

Plasters. — (a) Belladonna (use as a local sedative 
in neuralgia, mastitis, adenitis; remove if dryness of 
throat or disordered vision occurs — the first symp- 
toms of belladonna-poisoning) ; (b) mercury (used for 
its resolvent effect upon indurated glands, chronic 
arthritis); (c) adhesive, "American surgeon's adhesive 
plaster" (contains rubber and adheres without heating); 
(d) resin plaster (requires heating to adhere). 

Collodion and cotton are used to support and seal 
external flaps and wounds. 

Massage consists of manual manipulations of a part 
for the purpose of stimulation. May be applied twice 
daily, once daily, or every other day; each application 
may last from twenty minutes to one hour. 

The movements of massage are: (i) Rubbing (strok- 
ing movements, gentle at first, afterward of increasing 



228 SURGICAL TECHNIC 

firmness); (2) kneading (rolling, circular, pinching 
movements) ; (3) tapping (percussion over the surface 
with the leveled finger-tips produced by flexion, ulnar 
side of the hand, or by the use of a mechanical muscle- 
beater) ; (4) passive motion (elevation, flexion, and 
contraction of the parts produced by the operator). 

Clinical Thermometer. — May be of Fahrenheit (com- 
mon form) or Centigrade scale. To reduce readings — 
(1) Fahrenheit to Centigrade: Subtract 32 from the 
number of Fahrenheit degrees and multiply the re- 
mainder by f; (2) Centigrade to Fahrenheit: Multiply 
the number of Centigrade degrees by f and add 32. 



95 
Fig. 187. — Clinical thermometer. 

Thermometers may be — (a) straight, self-registering 
(90 to no° F. — 33.3°-444° C); (b) surface, coiled or 
bulb (8o° to no° F.— 26.6 -444° C). 

Temperature may be taken in — (a) Mouth; (b) 
axilla; (c) rectum; (d) vagina. Most exact in vagina 
and rectum. Mouth-temperature is higher than that of 
the axilla and less than that of the rectum. Axilla-tem- 
perature is somewhat less than a degree below the rectal. 

Electricity is used (a) As a muscle tonic ; (b) for nerve- 
sedative action employ that form of electricity which gives 
the best contractions with the least amount of pain and 
discomfort to the patient; (c) electrolysis (used in the 
treatment of aneurysm, tumors, for the removal of super- 
fluous hair) ; (d) cautery, ecraseur (is followed by least 
hemorrhage when used at a dull-red heat). 



MINOR SURGICAL PROCEDURES 229 

The thermocautery, known also as the Paque'lin cau- 
tery, because of its invention by Paquelin, of Paris, is 
frequently employed in surgery to control bleeding, and 
also to produce counterirritation. The efficacy of this 
instrument depends on the fact that when the vapor of 
some highly combustible carbon compound is driven over 
heated platinum its rapid incandescence is sufficient to 
maintain the heat of the metal. Platinum points of 
various shapes and sizes are attached to a rubber tube, 




Fig. 1 88. — Paquelin's cautery. Note that the benzin is contained in the 
handle of the apparatus. (W. E. Ashton.) 

which is connected with a metal container half full of 
benzin or alcohol, the vapor of which is pumped through 
the tubing and holder into the platinum point. In order 
to prepare the instrument for use, benzin (above 65 F., 
Baume) is the best combustible, but wood alcohol, naph- 
tha, benzol, gasolene, ammonia- water, or ether may be 
used. 

After using the container should be completely closed, 
and the points while hot must be removed from the 
handle and laid away to cool; they must not be put into 



23O SURGICAL TECHNIC 

water, but wiped perfectly clean. The handle when cool 
must be removed from the tubing, and each part must be 
laid in its own compartment in the case. 

Where possible electric thermocauteries are preferable 
for the reason that they do not get out of order. 

POISONS AND ANTIDOTES 

Acids, Mineral. — Give chalk, flour, white of egg, 
magnesia (plaster torn off the wall may be used in an 
emergency) ; a solution of carbonate of soda ; emollient 
drinks; fixed oils (sweet oil, olive oil, cod-liver oil). 
Give plenty of water to dilute the acid. 

Acid, Carbolic. — Any soluble sulphate (magnesia), 
alcohol acts as a direct antidote if given during the 
first ten or fifteen minutes; whisky may be employed 
for the purpose. 

Acid, Hydrocyanic. — Secure plenty of fresh air; carry 
on artificial respiration; apply cold affusion; ammonia — 
inhalation and intravenously in a vein. 

Aconite. — Give emetics; stimulants (external and 
internal) ; keep up the body heat ; patient is to be placed 
flat on his back. 

Antimony Tartrate. — Give vegetable acids — tannic 
acid (gr. v-xv — 0.333-1 gm.), catechu (foj-ij — 4-8 
c.c). 

Arsenic. — Give freshly precipitated hydrated ses- 
quioxid of iron (made by adding magnesia to any iron 
solution) . 

Atropin, Belladonna, Stramonium. — Emetics (mus- 
tard flour in water) ; apply cold to the head ; give physos- 
tigma (gr. -^-\ — 0.006-0.013 gm.) or pilocarpin (gr. 
I — 0.008 gm.). 



MINOR SURGICAL PROCEDURES 23 1 

Cantharides. — Give emetics; emollient drinks; opium 
(g r - i~2 — 0.016-0.033 gm.) by mouth and rectum; large 
drafts of water to flush the kidneys. 

Chlorin-water. — Give albumin (white of egg, milk, flour). 

Chloroform. — Secure plenty of fresh air, carry on 
artificial respiration (inclining head down, pull the pa- 
tient's tongue forward) ; brandy and ammonia intrave- 
nously; hypodermic injection (15 min. — 1 c.c.) of tincture 
of digitalis; gr. gV (0.001 gm.) of atropin. 

Colchicum. — Give emetics, followed by demulcent 
drinks ; keep up external heat. If coma is present, brandy, 
ammonia, coffee. Opium in large dose. 

Conium. — Give emetics; stimulants (external and 
internal) . 

Copper Sulphate. — Give yellow prussiate of potash 
(may be given freely if pure); soap. 

Corrosive Sublimate. — Give albumin (white of egg 
— 4 gr. (0.266 gm.) of sublimate requires the white of one 
egg), flour, milk; equal parts of lime-water and milk; 
emetics or stomach-pump. 

Croton Oil. — Give emetics; wash out the stomach; 
mucilaginous fluids containing opium. 

Digitalis. — Give emetics; recumbent position; tincture 
of aconite (1-5 drops — 0.066-0.333 c.c); opium (gr. 
i-J— 0.16-0.033 gm.). 

Elaterium. — Give demulcent drinks ; enemata of opium ; 
external heat. 

Hyoscyamus. — Stomach-pump; give emetics; stim- 
ulants, (external and internal) ; physostigma, (gr. yg — 
0.0006 gm.); pilocarpin (gr. J — 0.008 gm.). 

Illuminating- gas . — Hypodermic injection (1 min. — 
0.066 c.c.) of nitroglycerin; carry on artificial respiration. 



232 SURGICAL TECHNIC 

Iodin. — Give emetics; demulcent drinks (starch or 
flour in water); opium (gr. |-| — 0.016-0.033 gm.); 
external heat. 

Lead Salts. — Give any soluble sulphate (magnesia or 
soda) . Follow with emetics, opium (gr. \-\ — 0.016-0.033 
gm.), and milk. 

Lobelia. — External and internal stimulation. 

Morphin; Opium. — Atropin (gr. y-J-j- — 0.006 gm.) hypo- 
dermically until respirations number eight a minute; 
stomach-pump; stimulants (external and internal) 
brandy ; strong coffee ; cold affusion ; ammonia to nostrils ; 
galvanic shocks; compelling patient to move about; 
artificial respiration ; permanganate of. potassium ; cocain 
(g r - i~i — 0.016-0.033 £ m -) ; repeat if necessary. 

Oxalic Acid. — Give lime (plaster, lime-water, milk of 
lime). 

Phosphorus. — Sulphate of copper in emetic dose as 
a chemical antidote; emetics; purgatives. No oils. 

Potash and Soda Salts. — Dilute acetic acid; citric 
acid; lemon-juice; vinegar; fixed oils; demulcent drinks. 

Silver Nitrate. — Solution of common salt; demulcent 
drinks; emetics. 

Strychnin; Nux Vomica. — Give 30 grains (2 gm.) of 
chloral and 60 grains (4 gm.) of bromid of potassium; 
nitrate of amyl. 

Tobacco. — Emetics; stimulants (external and internal); 
strychnin (gr. ^o~T5 — 0.0022-0.0044 g m -)- 

Zinc Salts. — Carbonate of soda; emetics; warm de- 
mulcent drinks. 

Poisonous Fish. — Emetics to wash out the stomach; 
purgatives ; stimulants. 



CHAPTER XIII 

OBSTETRIC NURSING, CARE OF INFANTS, ETC. 

Professor Hirst has employed printed slips contain- 
ing the following directions to the nurse: 

BEFORE LABOR 

I. Have ready towels; ether, ^ pound; brandy, 2 
ounces; vinegar, 4 ounces; hot water; a bottle of anti- 
septic tablets; a large, new sponge; a roll of narrow tape 
or skein of bobbin; a fountain-syringe; bed-pan; new, 
soft-rubber catheter; 4 dozen small, 2 dozen large, 
pads; small package of salicylated cotton; absorbent 
cotton. 

II. Give a rectal injection (a pint of soapsuds with 

teaspoonful of turpentine) as soon as labor-pains are 

well established. 

AFTER LABOR 

III. No vaginal injection to be given unless ordered. 

IV. Take the temperature three times a day — morn- 
ing, noon, and evening. 

V. Place large pad under patient. Occlusive bandage 
to be used as directed. 

VI. The external genitals to be washed off four or 
five times a day with a warm corrosive sublimate solu- 
tion, 1 : 2000. Use absorbent cotton. 

VII. If, at the end of twelve hours, the bladder can- 
not be emptied naturally, use a catheter. Afterward, 
if necessary, catheterize patient three times a day. 

233 



234 



SURGICAL TECHNIC 



VIII. The patient is to lie on her back; she may 
be moved from one side of the bed to the other several 
times a day; her limbs may be rubbed with alcohol and 
water or bathing whisky once a day. 




Fig. 189. — Bed arranged for childbirth: The mattress is protected by a 
mackintosh, over which a clean sheet is spread. The upper bedclothes 
are rolled up at the foot of the bed. The woman's buttocks rest upon a 
square yard of nursery cloth. The chair is for the obstetrician; at his feet 
is a waste-bucket, into which the pledgets of cotton used to clean the anus 
are thrown. The table, in easy reach, has upon it a large basin of sub- 
limate solution, 1 : 2000, in which are many large pledgets of cotton; a 
small tin cup on an alcohol lamp to boil the scissors for the cord; a half- 
dozen clean towels; a pot of carbolated vaselin, a tumbler of boric acid 
solution with squares of clean soft linen in it for the child's eyes and 
mouth; a tube of sterile silk for the cord. (Hirst.) 

IX. The nurse's hands are to be washed with nail- 
brush, soap and water, and rinsed in a 1 : 3000 sub- 



OBSTETRIC NURSING; CARE OF INFANTS 235 

limate solution before catheterizing the patient, cleansing 
the genitals or breasts. 

Diet. — First Forty-eight Hours. — Milk, \\-2 pints a 
day, gruel, soup, one cup of tea a day, toast and butter. 

Second Forty-eight Hours. — Milk-toast, poached eggs, 
porridge, soup, cornstarch, tapioca, wine jelly, small raw 
oysters, one cup of coffee or tea a day. 

Third Forty-eight Hours. — Soup, white meat of fowl, 
mashed potatoes; beets in addition to above. 

After sixth day return cautiously to ordinary diet. 
In addition to three meals a day give three or four glasses 
of milk through the day. 

Child. — I. After being well rubbed with sweet oil, 
the child is to be bathed in water of 90 + ° F. ; this should 
be the temperature of the daily bath. Use a bath-ther- 
mometer, or else the water will often be too hot. 

II. The cord is to be dressed with salicylated cotton. 
Observe carefully for bleeding. 

III. It should be bathed daily, about midday, in the 
warmest part of the room. Use Castile soap and a soft 
sponge; avoid the eyes. 

IV. The bowels of a healthy infant are moved four 
times a day, the urine voided six to twenty times. It is 
usually necessary to change the diapers eighteen to 
twenty-four times a day. Use compound or bora ted tal- 
cum powder, lycopodium, zinc oxid, or rice flour. In case 
of chafing, cold cream and borated talcum flour. Note 
the color of stools. 

Nursing. — The child is to be put to the breast every 
four hours during the first two days. No other food is 
to be given it. After the second day it should be nursed 
every two hours from 7 A. M. to 9 P. M., and twice during 



236 



SURGICAL TECHNIC 



the night (i and 5 A. M.). After every nursing the 
nipples are to be carefully washed with a piece of ab- 
sorbent cotton, warm water and Castile soap, and then 
smeared with a little sweet oil. 

Clothing. — If born during the winter season a baby 
should be clothed as follows: A binder of flannel or knit 
wool twice around abdomen; a knit shirt, diaper, knit 
woolen shoes, and two skirts, the first flannel (in mid- 
summer, linen), and finally its dress. The skirts should 
3/TT- 




Fig. 190. — The Murphy breast-binder. 



be supported from the shoulders by sleeves or tapes. 
A knit jacket may be worn over the dress. A light flannel 
shawl or cap will protect the child from attacks of head 
cold (coryza). 

Feeding. — The average stomach capacity of a new- 
born infant is 1 ounce, and it increases 1 ounce per 
month up to six months. A child should never be 
nursed while it lies in its crib, but be taken up in the 
arms. Young mothers experience great pleasure in 
suckling a child, and may put it to the breast even- fifteen 



OBSTETRIC NURSING; CARE OF INFANTS 237 

or thirty minutes, giving rise to derangement of the in- 
fant's bowels which may become serious. 

Artificial Feeding. — Asses' and goats' milk are most 
like human milk. An infant cannot begin to digest 
starchy foods under nine months of age, hence all pre- 




Fig. 191. — Schultze's method of artificial respiration: A, Inspiration; 
B, expiration. (Hirst.) 



pared foods are injurious according to the amount of 
starch contained. 

Milk Mixtures. — (a) For first twelve or fourteen days 
take: 

Condensed milk, 1 teaspoonful. 

Boiled water, 3 tablespoonfuls. 

Cream, 1 teaspoonful. 

Lime-water, 1 
Stir. 



238 



SURGICAL TECHNIC 



(b) After fourteenth day up to third month the fol- 
lowing may be used: 



Milk, 

Boiled water, 
Cream, 
Lime-water, 
Maltine (Merck's), 



i tablespoonful. 
5 teaspoonfuls. 
I teaspoonful. 
i 
10 grains. 



Stir. 



After the third month increase the amount of milk 
to 5 teaspoonfuls, and reduce the boiled water to 4 tea- 
spoonfuls. 

(c) A mixture for general use may be made according 
to the following formula: 
Milk, 1 ounce, 
Boiled water, 1 ounce, 
Cream, 
Lime-water, 
Malt sugar (malt extract), 1 coffeespoonful. 
Stir together. 

Absolute cleanliness of all milk bottles, spoons, 
dippers, and rubber nipples is necessary, or deranged 
digestion if not serious bowel disorders will assuredly 
result. They -should be boiled. 



2 tablespoonfuls. 

2 

2 teaspoonfuls. 

2 



CHAPTER XIV 

OPERATIONS; PREPARATION OF THE OPERAT- 
ING-ROOM; THE SURGEON AND HIS AS- 
SISTANTS 

Surgery has two objects, to prolong life and to 
relieve suffering. If it accomplishes either of these 
objects it succeeds. To prolong life or to relieve suf- 
fering divides operations into several classes, because 
they occur with more or less urgency according to 
the condition the patient is in. 

We often hear it said of an operation that it is one 
of necessity; of another, that it is one of emergency; 
and of another, that it is one of expediency. For 
convenience, operations are divided into two classes: 
First, operations of necessity; second, operations of 
expediency; and the first class may be subdivided 
into emergency and elective operations. 

Operations of expediency are those which it would be 
well to perform for the health of the patient, as, for 
instance, the removal of a malignant growth of the 
breast. If left to itself, the growth will slowly and 
gradually invade the internal organs and in a very 
few years will end life; while if removed, the patient 
will in all probability live a number of years, and there 
may be immunity for a long period before the disease 
returns. 

Operations of necessity are performed to save the 
life of the patient, as, for example, in cases of intes- 

239 



240 SURGICAL TECHNIC 

tinal obstruction, in hemorrhage from rupture of an 
extra-uterine pregnancy, etc. 

Emergency operations are those which must be per- 
formed immediately, without any choice, such as trache- 
otomy. 

An elective operation is at the choice of the patient, 
as in a hernia. 

Preparation of the Operating-room. — The operating- 
room should be made as aseptic as possible; the walls 
and floor should be washed with corrosive sublimate 
solution (1 :200o). The operating- table, stands, chairs, 
and other furniture, which are usually of glass and iron, 
should be washed with the sublimate solution. The 
sterilizer, which has been packed with the dressings, 
blankets (2), sheets (2), towels, caps, suits, and gowns 
for the operator, assistants, and nurses, should be 
started two hours before the operation. The instruments 
should boil fifteen minutes for their final sterilization 
before the operation in a 1 per cent, soda solution. 
Everything that will be needed for the operation and 
for possible accidents must be in the operating-room, 
and within easy reach. The solutions used should be 
quite warm, both for the surgeons and patient. We 
often come across a nurse who when she has filled the 
basins will put in her non-sterile hand to see if the water 
is too hot or too cold. We can readily tell from the out- 
side of the basin if the water is of the proper temperature. 

At all major operations four nurses are necessary — 
the head nurse, who has charge of the instruments; 
a second nurse, to take charge of the sponges; a third 
nurse, to keep ready for the operator a basin of sterile 
water to enable him at any time to quickly rinse his 



operations; preparation of operating-room 241 

hands to remove septic fluid or to free his fingers from 
blood and clots, and attend to the irrigation, etc.; a 
fourth nurse, to handle unsterilized articles. Each 
nurse should have a clear idea of her duties, and dis- 
charge them without undertaking the duties belonging 
to another. If the dry technic is used, the head nurse 
can hand the sponges as well as the instruments, and 
this gives a nurse to wait on her exclusively. Under no 
consideration should the head nurse be left alone for a 
single moment, as the operator might call for something 
which she, being "surgically clean," could not touch, and 
so cause a probable delay in the operation. 

The duties of the nurses in the operating-room are 
the same for all operations. The dress must be of 
washable material, preferably white; it should be fresh 
for the operation and as far as possible sterilized. A 
dress that has been through the wards is not clean; 
neither is one that has been worn a day or half a day. 
The dress-sleeves should be unbuttoned so that they 
.can be rolled up above the elbow, to allow the arms to be 
made as sterile as possible, and so that the sleeves may 
not come in contact with anything used in the operation 
itself. The finger-nails must be cut short. On first 
going to the operating-room the hands and forearms 
should be scrubbed with a brush and green soap and run- 
ning water as hot as can be borne for ten minutes by the 
clock. The cleaning of the finger-nails is very impor- 
tant, as many of us would be surprised to find the large 
number of germs taken from under the finger-nails as 
the result of one cleansing. 

The hands and forearms are' then rendered sterile by 
putting them first into a saturated solution of perman- 
16 



242 SURGICAL TECHXIC 

ganate of potassium until they are of a deep-brown color 
from the tips of the fingers to the elbow, then into a hot 
saturated solution of oxalic acid until all the permangan- 
ate stain has been removed; they are then washed in 
sterilized hot water, and finally are soaked for three 
minutes in a solution of corrosive sublimate (i : iooo). 
The solutions reach those corners and crevices in the 
finger-nails that cannot be reached by the brush. 

Some surgeons prefer ether and alcohol for cleans- 
ing the skin. After the hands have been scrubbed 
thoroughly in hot soapsuds and the finger-nails cleaned, 
the hands are washed in ether, which removes from the 
skin all oily and fatty substances; they are next washed 
in pure alcohol for one minute, and finally soaked for 
three minutes in a solution of corrosive sublimate (i : 
iooo). The field of operation is cleansed in the same 
manner with ether, alcohol, and the sublimate solution, 
or painted with 5 per cent, tincture of iodin. In using 
iodin be sure no water has been on the area for several 
hours; if so, wash first with alcohol (95 per cent.). Bi- 
chlorid of mercury should not be used with iodin, as a 
burn will be produced. 

The nail-brushes used should be absolutely sterile. 
They must be new, and need to be boiled for one-half 
hour on the day of the operation. A dirty nail-brush is 
the haven of myriads of germs and their spores, and by 
using such a one we place more germs on our hands than 
were there before they were touched. 

Before going to operation nurses and doctors should 
be attired in sterile suits, caps, and masks. They should 
then disinfect their hands and long sleeved gowns and 
rubber gloves be put on. The cuffs of the sleeves should 



operations; preparation of operating-room 243 



4 




be encased in the rubber gloves. After making the hands 
aseptic it is essential that they do not come in contact 
with anything that has not been made aseptic before the 



244 



SURGICAL TECHNIC 



operation is commenced, for such is very easy to occur 
unless the nurse is constantly on her guard against it. 

The surgeon and his assistants prepare for the opera- 
tion very much the same as does the nurse. Many 
surgeons before operating take a corrosive sublimate 





Fig. 193. — a, Long-sleeved gown; b, the same, showing glove with gauntlet 
turned up over wristband of gown. (Hirst.) 



bath (1 1500), after which they put on clean linen 
suits or long gowns and prepare their hands and fore- 
arms. The suits, which have been sterilized in bags 
or folded in a sheet, are taken from the sterilizer by 
the head nurse, and placed in the dressing-room 
about one hour before the arrival of the surgeons, 



operations; preparation of operating-room 245 





so 



that they may be perfectly dry when required 
for use. They should not be hung over the back of a 
chair or laid over a table for dust to collect upon them. 



246 SURGICAL TECHNIC 

We must bear in mind that after sterilization there is 
always the danger of contamination, and the articles 
must be carefully protected as soon as they are removed 
from the sterilizer. To avoid confusion, each suit 
and bag should be distinctly marked with the owner's 
name, as should also the white canvas shoes which 
some surgeons wear. The caps must be laid in the 
dressing-room, together with long strips of sterilized 
gauze to cover the beard and mustache. 

Spectators should remove their coats and wear long 
sleeveless linen gowns. The nurses should not leave the 
operating-room unless it is absolutely necessary, and there 
should be no unnecessary opening of doors, which allows 
cold air to enter. Constant moving also causes dust to 
become stirred up. The temperature of the operating- 
room should be 8o° F., and the air kept perfectly pure 
by thorough ventilation, which should be so arranged that 
drafts will be avoided. 

With the kind permission of Dr. F. W. Johnston, 
of Boston, I extract the following from his paper on 
"Two Years' Work with the Sprague Sterilizer in the 
Gynecologic Department a£ St. Elizabeth's Hospital, 
Boston, Mass.," which shows the great necessity of 
absolute cleanliness and how easily infection takes 
place from dust in the room: 

"I was especially anxious to ascertain if any pus- 
producing organisms should be found in the dust. 

"The operating-room is kept as clean as soap and 
water and corrosive sublimate can effect the cleanli- 
ness of its floor and walls. 

"The following is the report of E. A. Darling, formerly 
Assistant in Bacteriology, Harvard Medical School: 



operations; preparation of operating-room 247 

"Four Petri double dishes containing films of sterilized 
and coagulated blood-serum were exposed in various 
parts of the operating-room during a celiotomy, the 
period of exposure varying from one hour and twenty 
minutes to one hour and fifty minutes. 

'The plates were exposed during the middle of the 
forenoon of December 28, 1897. 

"One dish was placed on the floor, where we supposed 
the dust would be kept in the most active motion by our 
feet and the nurse's dress; one was placed on the stand 
holding the sponge-pails; one was placed on the patient's 
knees raised in the Trendelenburg position, and one was 



Fig. 195. — Petri dish for making plate cultures. 

placed on the table beside the instrument tray. The 
•dishes were uncovered just as the knife went through the 
skin. 

"At the conclusion of the operation the dishes were 
covered, conveyed to the bacteriologic laboratory, and 
placed in the incubator at 37 C. for several days. 

"After twenty-four to seventy-two hours the plates 
were opened and the colonies counted. 

"At the same time an attempt was made to determine 
the varieties of bacteria present, and particularly to 
demonstrate the presence or absence of the pyogenic 
forms. 

"Cover-glass preparations»and cultures were made from 



248 SURGICAL TECHNIC 

as many different kinds of colonies as could be dis- 
tinguished. 

"The results are. in brief, as follows: 

"Plate A. Spofige table, exposed 1 hour 50 minutes: 
after 24 hours showed 216 colonies: 72 hours. 296 colonies. 

"Plate B. Knees of patient, exposed 1 hour 20 min- 
utes: after 24 hours showed 156 colonies; 72 hours, 280 
colonies. 

"Plate C. Floor, exposed 1 hour 50 minutes: after 
24 hours showed 296 colonies; 72 hours. 42 S colonies. 

"Plate D. Instrument table, exposed 1 hour 40 min- 
utes: after 24 hours showed 216 colonies; 72 hours. 256 
colonies. 

"The varieties of bacteria present were studied mi- 
nutely on Plate B (the one on the patient's knee), less 
carefully on Plate D (the one on the instrument table). 
Of the recognized pyogenic cocci, two varieties were 
found — the Staphylococcus albus (15 colonies on Plate 
B. 20 colonies on Plate D) and the Staphylococcus 
aureus (3 colonies on Plate B. 4 colonies on Plate D). 

"The remaining colonies on both plates were sar- 
cinae of several kinds, yellow, orange, and white molds. 
and several varieties of unrecognized bacilli and cocci. 

"As would be expected, the plate from the floor 
showed the largest number of colonies. Plate B (the 
one on the patient's knee most interested me. 

"The finding by Dr. Darling of fifteen colonies of the 
Staphylococcus albus and three colonies of the Staphy- 
lococcus aureus on this small plate within a few inches 
of the opened abdominal cavity was certainly an object 
lesson, and has given lots of food for reflection." 



CHAPTER XV 

TRANSPORTATION; PREPARATION OF PATIENT 
FOR OPERATION; CARE OF PATIENT DUR- 
ING AND AFTER OPERATION 

Transportation. — The entire duty of attending to 
the transfer of a patient to or from home and hospital 
may fall upon the nurse. The following suggestions 
are made by Mr. Scully, who conducts a private ambu- 
lance business in New York. The transportation of 
a patient, in order that it may be safely and pleas- 
antly accomplished, requires attention to detail. The 
nurse or friends of the patient should attend to the 
requirements for admittance by the hospital authori- 
ties, such as the hours of admission, financial details, 
and presentation of a written statement of diagnosis 
by the family physician. Other things being equal, 
it is better in the summer months to remove a patient 
early in the morning or toward evening; in the winter, 
near midday. Give as much notice as possible in order 
to secure the best attention from the ambulance service. 
Have the patient ready at the hour arranged. Nothing 
is more trying to the patient than to be delayed, either 
by friends or by non-arrival of the ambulance. Do not 
disturb the patient by insisting on a perfect toilet; an 
ample supply of covering is the chief necessity. Neces- 
sary articles of clothing which a patient should bring 

249 



250 SURGICAL TECHNIC 

to a hospital are: 4 night-gowns or pyjama suits; 4 
suits of underwear; 4 pairs of stockings; slippers, bath- 
robe ; hair-brush and comb ; tooth-brush and tooth powder 
or paste; handkerchiefs, and other toilet articles. The 
nurse should accompany the patient in the ambulance, to 
give any needed attention and complete the arrangements 
with the hospital authorities. Jewelry and valuables 
should be checked at the hospital office. In transporting 
to and from railroads and steamships ample notice 
must be given to make connections. For all distances 
up to thirty-five miles, direct transportation by ambu- 
lance is preferable to train service, especially in cases 
of very sick patients. 

Preparation for Operation. — The methods given here 
for preparing the patient for abdominal operations may 
serve as a reliable guide to the nurse, who is more or less 
responsible for preparatory treatment. The methods of 
preparation of all kinds are subject to change in detail, 
because surgical methods are constantly advancing 
and changing, though the general principles remain. 
It should be remembered that patients rally much better 
from an operation when they have been properly pre- 
pared both externally and internally. 

Day Before Operation. — The patient receives a full 
bath and the hair is washed. A cathartic is given — 
castor oil, citrate of magnesium, or salts. The diet 
should be nourishing and light. Milk is not given before 
an abdominal operation, because the stomach may not 
digest it thoroughly, and its curds may remain in the 
intestines and act as an irritant. Gruel is nourishing 
and easily digested. No food is given after midnight. 



PREPARATION OF FIELD OF OPERATION 25 1 

PREPARATION OF FIELD OF OPERATION 

1. Scrub the parts with green soap and stiff brush. 

2. Shave from nipples to rectum. Chemical hair- 
remover may be used; acts by dissolving the hair, but 
may prove too irritating to some skins. 

3. Scrub again and rinse thoroughly with sterile 
water. 

4. Rub well with alcohol, followed with ether, to re- 
move fats. 

5. Wash with corrosive sublimate (i : iooo), and put 
on an antiseptic dressing, consisting of five dressing- 
pads, one layer of common cotton, one dressing over 
that, then abdominal binder. The patient must be 
instructed not to put her fingers underneath the dressing 
nor to disturb it in any way. 

A simpler method, and one frequently used, consists 
in a tub- or bed-bath. 

Completely shave the parts to be operated upon at 
least six hours before the operation. 

Paint the operative area (excepting vulva or rectum) 
with tincture of iodin (5 per cent.). 

Prepare the vaginal canal by shaving the parts and 
giving a warm douche (lysol, I per cent.) and cover the 
vulva with a dressing. Use perineal straps to keep the 
dressing and abdominal binder in position. See that the 
dressings are kept wet with the antiseptic ordered until 
the patient is taken to the operating-room. This prepa- 
ration should be made twelve hours before an operation. 

Biniodid of mercury is sometimes dissolved in the 
ether, making a solution of 1 : 1000, which, besides 
removing all fatty substances from the skin, is also a 
disinfectant. When the skin is very dirty it is scrubbed 



252 



SURGICAL TECHNIC 



with benzin, then with alcohol, and then with the bin- 
iodid solution. 

Day of Operation. — Flush out the colon and give a 
bath; take off all flannels, put on a gown open at the 
back, and cotton-flannel stockings. Cleanse teeth, 
mouth, nose, and throat with a boric acid solution and 
brush. Catheterize just before sending the patient to 
the anesthetizing room if the operation is on the uterus 
or its appendages. Always catheterize in other opera- 




Fig. 196. — Solution basins stand. 



tions if the patient is unable to urinate. Envelop the 
hair in a sterilized towel. 

Remove all rings and ear-rings; also false teeth, 
whether a whole or a partial set, as there is danger of their 
being swallowed. Envelop feet and lower limbs in a warm 
blanket securely pinned .around the hips with safety-pins. 
Besides preserving the heat, this arrangement will pre- 
vent the patient from tossing the limbs about while taking 
the anesthetic. Many operators give morphin (gr. J) 



PREPARATION OF FIELD OF OPERATION 



253 



and atropin (yj-g- grain), hypodermically, half an hour 
before the operation to quiet the patient and prevent 
an increase in the saliva. 

Arranging the Patient for the Operation. — The patient 
having been placed on the operating- table, the clothes 
are removed from the part to 
be operated upon, and sterilized 
blankets are tucked about the 
chest, the edges being tucked 111 j 

under the back to reduce as far £ 

as possible the loss of body heat, 
and the bandage and pad are re- 
moved from the field of operation, 
which is again thoroughly cleansed 
with soap and water and disin- 
fectants. An assistant nurse hands 
the sterilized water, green soap, 
and scrubbing-brush to the assist- 
ant surgeon. The soapsuds are 
rinsed off with sterile water, the 
part is sponged with alcohol and 
bichlorid solution. This final scrub- 
bing should be done in the anes- 
thetizing room if possible while the 
patient is being anesthetized, to 
avoid delay in the operating-room. 
A far simpler method is to paint the 
part with a 5 per cent, solution of 
iodin. A sterilized sheet, having an oval opening in the 
center through which the section is made, and towels 
are then arranged around the field of operation. The 
instruments are taken from the sterilizer and placed in 




Fig. 197. — Irrigator. 



254 



SURGICAL TECHNIC 



trays containing sterile water or upon dry sterile towels. 
A written statement of the instruments laid out must be 
made. The number before and after the operation must 
tally. 

Some surgeons use the prepared sponges. These 
must be reliably counted before the operation by the 
operator and assistants, and the number written down, 
so as not to trust to memory. Sponges must be squeezed 




Fig. 198. — Towels pinned over rubber dam, leaving no skin surface ex- 
posed. (Hirst.) 



almost dry before they are handed to the surgeon, be- 
cause it is only in an almost dry condition that they are 
of service. The nurse should not, while waiting to hand 
a fresh sponge, rest her hands or forearms on the pail. 
She should count the sponges before the surgeon begins 
to sew up the wound, and then should be very sure that 
she has the exact number employed in the operation. 
The large square sponges used for covering the intestines, 



PREPARATION OF FIELD OF OPERATION 



255 



or walling off small areas, should have a long piece of 
tape attached, and to this a forceps, so that if one should 
slip out of sight it can be readily located and recovered 
without undue handling of the bowel. After being used, 
the sponges are put into a pan or basin, and should not 
be disposed of until they have been accounted for before 
the abdomen is closed. 




Fig. 199. — Dressing table. 



Whatever has been removed from the body must be 
placed in a basin and laid aside in a safe place until 
the surgeon gives his directions as to whether or not 
he wishes it to be sent to the laboratory for examina- 
tion to make sure of its character, with a view to clearing 
up some obscure point about the nature of the disease. 

The head nurse attends to the instruments, sutures, 
and ligatures. If the dry technic is used, a basin of dry 
gauze sponges is placed on a table within easy reach of the 
operator's assistants. 

The assistant nurses must be on the alert to change 



256 SURGICAL TECHNIC 

the hand solutions when necessary, and to wipe the 
moisture from the face of the operator and his assistant 
with a sterilized towel, to prevent drops falling into 
the wound, and this must be done at a moment when the 
surgeons are not bending over the wound. They must 
move about the room very quietly but quickly. If asked 
to do anything that they do not understand, they should 
always inform the head nurse, who will make the duty 
clear. When emergencies arise and the operator is deal- 
ing with exceptional difficulties, the nurses must be on the 
alert to do quickly anything they may be called upon to 
do, each nurse discharging her duties without undertak- 
ing those belonging to another. It is absolutely neces- 
sary on such occasions to exercise self-control, and to fol- 
low the directions given without excitement or confusion. 

Just before the wound is closed the soiled towels 
are removed and replaced by fresh ones and a report 
given of the number of instruments and sponges missing, 
if they are not all accounted for. After the dressing 
has been applied the patient is raised, wiped perfectly 
dry, and a bandage put on. The blankets used to 
cover the feet and chest of the patient during the opera- 
tion should be tucked closely about the body and under- 
neath, and not merely be thrown over. 

Pneumonia and pleurisy after operation may follow 
as the result of chilling when in the operating-room, 
or exposure during the removal from the operating-room 
to the patient's room. 

When the patient is replaced in bed, which has been 
thoroughly warmed during the operation, the nurse 
should be present to take charge. The pillow should be 
removed and a towel placed for the head to rest upon. 



PREPARATION OF FIELD OF OPERATION 257 

The foot of the bed is elevated, this posture being main- 
tained for several hours, after which the bed is lowered. 
This is especially indicated in cases that have had spinal 
anesthesia. The heaters are placed about the patient's 
body outside a blanket; one thing being kept constantly 
in mind — not to burn the patient. A towel should be 
placed under the chin of the patient, and a small basin 
should be at hand to receive the vomited mucus, and this 
should be removed during quiet intervals. Nausea and 
vomiting may be relieved by saturating a towel with 
fresh, strong vinegar and holding it a few inches from the 
patient's face, laying it over the nostrils, or hanging it 
from the bedstead so that it will be near the patient's 
head. Oxygen hastens the recovery of consciousness 
and lessens the nausea. If administered with the anes- 
thetic there is almost complete absence of nausea — usu- 
ally none as soon as the patient is fully conscious. 

Dryness of the mouth and lips and thirst (which is 
often a troublesome feature) may be relieved by placing 
wet cloths on the lips, by allowing the patient to rinse 
out the mouth with cool water, and by frequent bathing 
of the hands and face with alcohol and tepid water or with 
plain water. If thirst is extreme, an enema of saline 
solution (1 pint) is given slowly. 

Infections of the Abdomen. — It is now an almost uni- 
form custom to place the patient in Fowler's position 
(sitting), and give them enteroclysis either by the 
Murphy drop method or frequent small enemas. A 
Gatch bed is the most satisfactory method of obtaining 
the Fowler position. 

The patient should not be left alone for a single 
moment during the first thirty-six hours after an ab- 
17 



25« SURGICAL TECHNIC 

dominal section if it can be avoided. The patient 
can do nothing for herself, and every want should be 
instantly supplied. I have known patients so eager to 
allay their thirst that they would get out of bed and 
drink water from the water-pitcher on the wash-stand 
and reach down for the hot- water bottle at the feet and 
drink part of the contents. One ward patient drank the 
water from an irrigator standing by the side of the 
next bed; another patient while in a semiconscious con- 
dition took the drainage-tube out of the abdomen, and 
when found by the nurse after a moment's absence from 
the room was sitting up on the edge of the bed. Watch- 
ing a patient recover from anesthesia is often monoto- 
nous ; but if this duty 7 is closely attended to, many dread- 
ful accidents will be avoided. 

A roll should be placed under the knees, so as to relax 
the abdominal muscles and also to remove the strain 
the patient would have to make in order to keep up the 
knees. A small flat pillow placed under the hollow of 
the back will relieve the backache of which so many pa- 
tients complain. 

Bladder and Bowels. — The catheter should be passed 
every six or eight hours if necessary, according to direc- 
tions, the most rigid aseptic precautions being taken. 
Flatulence may be very distressing; consequently passage 
of gas by the rectum is of good omen, as it shows that the 
bowels have regained their normal tone and there is no 
obstruction. After an abdominal operation the muscular 
walls of the intestines share in the weakness of the patient, 
and are not strong enough to overcome the contraction 
of the sphincter muscle. The accumulation of gas dis- 
tends the muscular fiber of the intestines, and, if not re- 



PREPARATION OF FI-ELD OF OPERATION 259 

lieved, would soon result in paralysis of the intestines. 
To prevent this a rectal tube is inserted to keep the 
sphincter dilated and to allow the gas to escape when it 
reaches that point. Purgatives, such as calomel (gr. T V 
every hour until I grain has been taken), are usually 
given twenty-four hours after the patient has recovered 
from the anesthetic to stimulate the intestines and keep 
up peristaltic action. 

Much fluid is not given for a few hours after the opera- 
tion, as it might cause vomiting or acute dilatation of the 
stomach. 

After recovery from the anesthetic, if there is no 
vomiting, cool water or toast-water is given in teaspoon- 
ful doses every fifteen or twenty minutes, the quantity 
being gradually increased and the intervals lengthened. 
The familiar cup of freshly made tea is sometimes the 
best drink to begin with ; it is always a pleasure under the 
circumstances to see the patient enjoy it, since it is 
not only refreshing but stimulating. If the stomach 
behaves well, tablespoonful doses of gruel or beef -essence 
may be given every half -hour. Milk is not given as a 
rule, as the curd may pass along the intestines and act 
as an irritant. For the first three days, and if there is no 
vomiting, nothing but liquids is given ; and after the third 
day soft and easily digestible food, which is gradually 
changed to a more solid diet. 

The external genitals should be kept perfectly clean, 
the body bathed, the bed- and body-linen kept sweet 
and clean, the teeth brushed, and the hair combed. 
Every want of the patient should be anticipated, and she 
should be made as comfortable as possible. Sponging 
the palms of the hands, the arms, and the legs will lead 



26o SURGICAL TECHNIC 

to the comfort of the patient. The luxury of a change 
into a fresh bed will often secure a good night's rest. 
Under no consideration should morphin be given except 
by the surgeon's directions, and every moral influence 
should be exerted to induce the patient to endure pain 
rather than resort to the drug. 

The nurse should not ascertain whether the patient 
is comfortable by continual questioning, but by unob- 
trusive observation. Questioning may alarm a patient 
and lead her to think too much about herself. 

No visitors should be admitted without the surgeon's 
consent. The mind of the patient is to be kept perfectly 
free from worry and excitement, and the whole atmos- 
phere of the room should be bright, pleasant, and cheerful, 
no matter what trouble is going on outside. 

A slight rise of temperature the day following opera- 
tion usually marks reaction from shock. On the eighth 
day the dressings are removed and the stitches taken out. 
The following week the patient sits up, and at the end 
of the third week she goes home. 

Many surgeons now shorten the time m bed to seven 
days. 

The following diet -list, dating from the third day, 
will be of assistance in varying the food. 

Fourth Day 

Breakfast. — Mutton-broth with bread-crumbs. 
L u nch . — M ilk-punch . 

Dinner. — Oyster broth, thin bread (with crust removed) 
and butter, sherry- wine. 

Lunch. — Cup of hot beef-tea. 
Supper. — Milk-toast, jelly. 



preparation of field of operation 26 1 

Fifth Day 

Breakfast. — Oatmeal with sugar and cream, cup of cocoa. 

Lunch. — Soft custard. 

Dinner. — Chicken soup or small piece of white meat of 
chicken, baked potato. 

Lunch. — Glass of milk. 

Supper. — Buttered milk-toast (crust removed), jelly, 
cocoa. 

Sixth Day 

Breakfast. — Soft-boiled egg, bread and butter, coffee. 

Lunch . — M ilk- punch . 

Dinner. — Chicken soup, tender sweetbreads, Bavarian 
cream. 

Lunch. — An egg-nog. 

Supper. — Tea, raw oysters, bread and butter. 

Seventh Day 

Breakfast. — Oatmeal with sugar and cream, a tender 
sweetbread, creamed potatoes, coffee, graham bread and 
butter. 

Lunch. — Glass of milk. 

Dinner. — Chicken panada, baked potato, bread, tapi- 
oca cream. 

Lunch. — Cup of hot chicken broth. 

Supper. — Buttered dry toast (crust removed), wine 
jelly, banquet crackers, tea. 

Eighth Day 
Breakfast. — An orange, scrambled egg, oatmeal with 
sugar and cream, soft buttered toast, coffee. 
Lunch. — Milk-punch. 



262 SURGICAL TECHNIC 

Dinner. — Cream of celery soup, a small piece of ten- 
derloin steak, baked potato, snow pudding, wine, bread. 

Lunch. — An egg-nog. 

Supper. — Calf's foot jelly, soft-boiled egg, bread and 
butter, cocoa. 

Ninth Day 

Breakfast. — Oatmeal, poached egg on toast, coffee. 

Lunch. — Cup of chicken broth. 

Dinner. — Chicken soup, small slice of tender roast 
beef, baked potato, rice-pudding, bread. 

Lunch. — Glass of milk. 

Supper. — Baked apples, raw oysters, bread and butter, 
orange jelly, tea. 

Tenth Day 

Breakfast. — Orange, mush and milk, scrambled eggs, 
cream-toast, coffee. 

Lunch. — Cup of soft custard. 

Dinner. — Mutton soup, small piece of tender beef- 
steak, creamed potatoes, sago pudding, bread, wine. 

Lunch. — Cup of beef-tea. 

Supper. — Sponge-cake with cream, buttered dry toast, 
wine jelly, cocoa. 

Eleyenth Day 

Breakfast. — Broiled fresh fish, oatmeal, graham bread, 
coffee. 

Lunch. — Chicken broth. 

Dinner. — Potato soup, breast of roasted chicken, 
masked potatoes, macaroni, blanc mange. 

Lunch. — Cup of mulled wine. 

Supper. — Cream-toast, lemon jelly, chocolate. 

The diet for other days may be selected from previous 
ones. The change of diet may cause a temporary rise 
in the temperature and pulse. 



CHAPTER XVI 

SEQUELS OF OPERATIONS; SHOCK, HEMOR- 
RHAGE, SEPTIC PERITONITIS, ACCIDENTS 
DURING OPERATION, ETC. 

As a rule, the average abdominal case passes into 
convalescence, especially when the case is in skilled 
hands and the operation has been performed in a fin- 
ished surgical way. Complications, however, are liable 
to arise in the simplest case, and throw great responsi- 
bility on both surgeon and nurse. It is in these, cases 
that the knowledge and skill of the nurse mean so much, 
and where the greatest triumphs of surgery are scored. 

A nurse has no moral right to take charge of a surgical 
case unless she has at her finger-ends the complications 
liable to arise, their symptoms, and the various means of 
meeting them until the arrival of the surgeon. 

Shock is great depression of the vital functions of 
the body brought on by injury or surgical operation. 
It is produced through the agency of the nervous sys- 
tem. The greater the injury, the longer the anesthesia, 
the greater the shock. The anesthetic enables the patient 
to undergo the operation without consciousness, but it 
does not prevent shock coming on afterward from the 
opening of the abdomen, the uncovering of the viscera, 
the handling of the intestines, and the exposure of the 
delicate sympathetic nerves in that part to the air and 
to touch. If to all this is added a long anesthesia, then 

263 



264 SURGICAL TECHNIC 

the prostration produced by the anesthetic is added to the 
effects of the operation. Dr. George W. Crile has lately 
combined local and general anesthetics, so that the nerve- 
centers will not receive any injuries. He calls his method 
anoci-association. 

Different individuals are differently affected: most 
persons are more susceptible to shock after months of 
hard work, or when the system is run down after an 
illness. Invalids stand shock very well, and indifferent 
persons stand it better than those who are despondent. 
The mental influence is very great: anything that de- 
presses the mind aggravates shock. It is here that the 
offices of the Church have such an effect on some patients 
in quieting apprehension and in adding fortitude. 

Age modifies shock. In old people shock is usually 
more severe and prolonged, especially if there is any 
organic disease. Children recover readily from shock if 
there has been very little loss of blood. Shock is com- 
bated to a certain extent by the patient's drinking a 
large amount of fluid for forty-eight hours before the 
operation, so that the blood-vessels of the vital organs 
will be well supplied with fluid during the operation. 
Experiments have been made which show that when the 
abdomen is opened the abdominal veins dilate, and as a 
consequence a large amount of blood in the body flows 
into them, thus leaving the heart and the vessels con- 
veying blood to the important nerve-centers at the base 
of the brain with very little fluid to work upon, and 
shock ensues. The output of the heart, as we know, is in 
proportion to the venous pressure, and if this is lowered 
the heart and the important nerve-centers at the base 
of the brain will be supplied with a diminished amount of 



SEQUELAE OF OPERATIONS 265 

blood. The intravenous injection of saline solution 
causes a rise in the venous pressure and an increase in the 
output of the heart. 

Two very important points to be considered in case 
of shock or of hemorrhage are the temperature and 
the condition of the patient's mind. In shock the tem- 
perature at first is normal or very little below normal, 
and the senses are dull in proportion to the degree of 
shock present; in hemorrhage the temperature is sub- 
normal, the mind is bright, keen, and alert, and there is 
an anxious expression on the face, as if the patient were 
anticipating danger. 

The symptoms of shock are a weak, rapid, and irregular 
pulse; sighing, rapid, irregular, and shallow respiration; 
a normal or slightly subnormal temperature; a pale face 
with a pinched look; a cold, clammy skin, and dulness of 
the mind. There may be involuntary movements of the 
bowels and urine as a result of loss of muscular power; 
nausea and vomiting may also be present. 

The treatment of shock consists in lowering the patient's 
head and raising the foot of the bed to increase the 
supply of blood to the vital centers; in the application 
of heat to all parts of the body, particularly the sides, 
between the legs, and to the feet; in placing a mustard- 
plaster over the heart; in administering whisky, brandy, 
or nitroglycerin hypodermically ; in giving hot black coffee 
by the rectum, or saline solution by hypodermoclysis or 
enteroclysis. Strychnin is a powerful stimulant, and 
should be given in doses of -^ grain every half-hour 
for four doses. Tincture of digitalis in 15-minim doses 
may be given every half -hour for four doses. As a rule 
in cases of shock there is a disposition on the part of 



266 SURGICAL TECHNIC 

nurses to do too much. Everything must be done in a 
prompt, quiet manner. For immediate stimulation in 
threatened collapse camphorated oil (15 minims) or 
adrenalin chlorid, hypodermically, are valuable. They 
are used for quick effect only, and not for prolonged 
stimulation of the heart's action. Stimulants must be 
given carefully, and time allowed to observe the effects 
produced, other measures being determined accordingly. 
An enema of § ounce of turpentine, a well-beaten raw 
egg, and 3 ounces of warm water constitutes a powerful 
stimulant. 

It must be remembered that in severe shock the 
function of absorption by the stomach and intestines 
is almost wholly suspended, and anything given by 
the rectum must be introduced high up. When the res- 
piration of the patient is fast failing, everything de- 
pends on maintaining the heart's action. To this 
end artificial respiration must be persistently prac- 
tised. A serious danger in performing artificial res- 
piration is that in our hurry we may make the motions 
too rapidly and not give the lungs time to fill thoroughly 
nor allow the air to be expelled before filling the lungs 
again. The motions should not be more frequent than 
sixteen to eighteen in the minute, so as to imitate as 
nearly as possible the natural rhythm of respiration. 

Recovery may be rapid or very slow; it is mani- 
fested by "reaction" — the pulse becomes more full, 
slow, and regular, the temperature rises, the body 
becomes warm, and a general improvement takes 
place. In rare cases the reaction becomes excessive 
and develops into traumatic delirium, which may be 
mild, low, and muttering, or of the wildest character. 



SEQUELS OF OPERATIONS 



267 



The skin is hot and flushed, the pulse full and regular, and 
the temperature above normal. This condition may 
subside and recovery take place, or it may be followed 
by collapse. 




Fig. 200. — Sylvester's method of artificial respiration (inspiration). 

(Fowler's Surgery.) 

Artificial Respiration. — As soon as respiration ceasec 
the mouth should be examined, if possible, for any obstruc- 
tion to the air-passages. If obstruction is found to be 
present, it should be removed or tracheotomy performed. 



268 



SURGICAL TECHNIC 



The most satisfactory method of artificial respiration 
consists in placing the patient with the upper portion of 
the abdomen resting upon a roll of material about I foot 
high. The head should be turned to one side. Then 




Fig. 201. — Sylvester's method of artificial respiration (expiration). 
(Fowler's Surgery.) 

rhythmic pressure should be made upon the lower ribs 
twenty times per minute. 

Sylvester's Method. — With the head and neck fully 
extended and the tongue drawn forward, the elbows are 



SEQUELS OF OPERATIONS 



269 



grasped and the arms gradually extended and then sud- 
denly compressed against the side of the chest. These 
motions should not exceed twenty to the minute. 

Laborde's Method. — This method may be used alone 
or in conjunction with the other methods. It consists 
in alternately drawing the tongue forward and pushing it 
back. If the above methods are not successful in four 




Fig. 202. — The Draeger pulmotor or automatic resuscitation device. 
(Keen's Surgery.) 



or five minutes, a lung motor or pulmotor should be 
employed. 

Hemorrhage may be caused by the slipping of a 
ligature or by the displacement of clots, as the result of 
restlessness or reaction of the circulation, and generally 
occurs within the first twenty-four hours after the opera- 
tion. The hemorrhage which comes from torn adhesions 
and bleeding surfaces is a free oozing, and seldom affects 
the pulse. When a drainage-tube has been used, it will 



270 SURGICAL TECHNIC 

usually indicate that there is hemorrhage by a flow of 
blood through the tube. This, however, cannot be relied 
upon, as only a moderate quantity of blood may flow 
through the tube, the abdomen being filled with clots. 

The symptoms of internal hemorrhage are restless- 
ness, thirst, faintness, an anxious expression, pale 



Figs. 203 and 204. — Esmarch's tourniquet, consisting of 9 feet of elastic 
webbing 23 inches wide, 3 feet tubular strap with chain. 

face, dilated pupils, cold skin,- frequent and irregular 
or sighing respiration, subnormal temperature, and a 
weak, rapid pulse (120 to 140). In rare cases the pulse 
is not greatly accelerated. 

Treatment. — The patient must be kept perfectly 
quiet on her back, the head being lowered and the 



SEQUELS OF OPERATIONS 27 1 

foot of the bed elevated. If symptoms of shock super- 
vene, heat is to be applied to all parts of the body by 
warm blankets and hot-water bottles. Stimulants are 
given only when the pulse is failing, as they excite the 
heart's action and increase the hemorrhage. When the 
hemorrhage has been excessive, infusion of saline solu- 
tion is resorted to, the fluid that the body has lost being 
thus replaced. Transfusion of blood is frequently indi- 
cated. Bandaging the limbs from their extremities up- 
ward is sometimes of use in keeping the blood in the 
vital organs. When the hemorrhage comes from a 




Fig. 205. — Bellocq's cannula, used for passing a cord through the nose, 
to be drawn out of the mouth, and gauze or cotton plugs attached for 
packing the nasal cavity for hemorrhage. (Morrow.) 

slipped ligature with large vessels pouring blood into 
the abdominal cavity, the abdomen is reopened and the 
vessel ligated. Everything should be ready for operative 
interference when the surgeon arrives, the same aseptic 
precautions being observed as in the original operation. 
For the free oozing from torn adhesions the tube is 
emptied frequently — every ten minutes. The drier the 
pelvic cavity is kept, the sooner will the hemorrhage 
cease. 

A noted surgeon has said that if an abdominal case 
escapes shock or hemorrhage, there is still a third danger 



27 2 SURGICAL TECHNIC 

to which the patient is liable, that of septic peritonitis. 
This is due to the entrance of germs into the peritoneal 
cavity, either from without or from ruptured abscesses or 
wounds. It may set in at any time from a few hours to 
six days after operation. The symptoms are pain in the 
abdomen and exquisite tenderness, distention, vomiting, 
constipation, icterus, restlessness, sleeplessness. 

The temperature rises a little, rarely going for a few 
days above ioo° or ioi° F.; but the pulse creeps up 
rapidly to 115, 120, or 130 beats per minute, and is weak 
and thready; although sometimes it is hard and "wiry" 
in the beginning. Then the temperature rises to 103 F. 
or above. The rectal or vaginal temperature may show a 
much higher rise than that of the mouth or axilla. In 
one typical instance the temperature taken in the mouth 
ranged between 101 and 102 F., the skin was cold and 
clammy, and the patient complained of intense thirst 
and a "burning up" feeling. The vaginal temperature 
was 108 F. In some of the worst cases the writer has 
seen the temperature was below normal, but the prostra- 
tion was severe. The abdomen is distended, due to dis- 
tention of the transverse colon by gas. There are nausea 
and vomiting. First the contents of the stomach are 
vomited, then bile, then a dark coffee-colored fluid which 
becomes more and more fecal in odor; a cold perspiration 
appears; the patient has a very anxious, pinched expres- 
sion, and is restless and talkative; the eyes are unusually 
bright, and there is a faint yellowish look about the skin 
and conjunctivae. As the disease continues the general 
system becomes poisoned. 

The treatment consists in providing drainage for the 
infection. The patient is placed in Fowler's position; 



SEQUELS OF OPERATIONS . 273 

salt solution is given by the Murphy method ; if vomiting 
occurs, the stomach should be washed out. Any stimu- 
lants that may be required are given hypodermically. 
All food by the mouth is stopped. If improvement does 
not follow, the surface of the body becomes cold and 
clammy ; the face pinched and sunken and of a dusky hue ; 
the restlessness increases, also the thirst, which becomes 
very great, and to the last the patient calls for water, 
which is vomited immediately after being taken, so 
should not be given. The mind usually remains clear to 
the end. 

Antistreptococcic serum has been used with fairly good 
results. It comes in glass tubes, sealed hermetically, 
and is injected hypodermically with antiseptic precau- 
tions into the thigh or the side of the breast, where there 
is considerable loose subcutaneous connective tissue. 
Another procedure of value is infusion of normal saline 
solution for the purpose of diluting the toxins in the 
blood and of removing them by the increased flow of urine 
which infusion brings about. 

Tympanites is often one of the earliest signs of septi- 
cemia, and when accompanied with a high temperature 
is usually a cause for anxiety, though it may be due to 
constipation, and in such cases is usually without sig- 
nificance. The treatment consists in the application of 
turpentine stupes, high enemata, and the insertion of the 
rectal tube for about 10 inches. Pituitrin in i-grain 
doses or eserin salicylate (4V grain) are valuable adjuncts. 

Fermentation fever is due to the absorption of fibrin 
ferment and the products of aseptic tissue necrosis. It 
causes a slight rise in temperature which need occasion 
no anxiety. 
18 



274 



SURGICAL TECHNIC 



Intestinal obstruction may be due to strangulation of 
a knuckle of intestine beneath inflammatory bands, or 
to its enclosure between the sutures in the wound. There 
is usually distention of the abdomen and later nausea and 
vomiting. Note should always be made if gas is heard 
rumbling in the intestines, and also if gas is passed and 
how often; also the result of the enemata which are ad- 
ministered to relieve the distention. 




Fig. 206. — General operating-table. 



Postoperative hernia is a sequel rather than a compli- 
cation of abdominal operations, and is due to a failure of 
union between the cut edges of the muscles and fasciae. 
As a rule, it does not occur until some weeks after the 
patient has returned home. It is to prevent this acci- 
dent that such stress is laid upon not allowing the patients 
to help themselves in any way without the surgeon's per- 
mission, so that the abdominal muscles may have sum- 



SEQUELS OF OPERATIONS 275 

cient time to become firmly united. This is also the 
reason why patients should wear an abdominal supporter 
for some months after their discharge. If hernia occurs, 
it is usually treated by a secondary operation. 

A sinus is often caused by imperfectly sterilized lig- 
atures or non-absorbable ligatures, which may cause an 
abscess around the point of ligation. This abscess may 
discharge itself into the intestine or vagina, or into the 
tract occupied by the drainage-tube through the ab- 
dominal wall. The sinus keeps open until the ligature is 
discharged or removed by another operation. 

Accidents During Operation. — Many times in difficult 
abdominal or vaginal operations the walls of the bladder 
may be torn, or one of the ureters or the intestines may 
be injured. When the ureter or bladder is injured, the 
urine sometimes passes through the incision to the dress- 
ing. This is called a urinary fistula. When the intes- 
tines are injured, fecal matter is discharged through the 
wound. This is a fecal fistula. 

Vaginal hysterectomy is the most serious of vaginal 
operations, but the nursing is the same as every opera- 
tive case requires. If clamps are used, they usually re- 
main attached for forty-eight hours. The handles are 
usually supported on a pad of absorbent cotton. In the 
handling of the clamps great care must be used,, as, for 
instance, when the patient is lifted on the bed-pan one 
nurse should lift the clamps. 

Postoperative insanity is an extremely rare complica- 
tion and is usually associated with premature menopause 
produced by the removal of both ovaries. The symp- 
toms are usually greatly ameliorated or cured by the 
administration of ovarian extract. 



CHAPTER XVII 

SPECIAL OPERATIONS 

Operations Upon the Head. — Nursing after opera- 
tions upon the brain calls for special diligence in watch- 
ing the patient during the first hours subsequently. 
Unlooked for symptoms may arise, and a change for 
better or worse in those accompanying the condition for 
which operation was performed; delirium, acute mania, 
or paralysis of some part or of the half of the body may 
develop, or, having been present, become rapidly altered 
in degree and aspect. Care to prevent the patient from 
injuring himself, falling from the bed or disturbing the 
dressing and doing direct injury after a trephining is 
necessary. Especially should the nurse be on her guard 
to prevent such patients being burned by hot-water 
bottles. Head operations being often long ones, or done 
for acute conditions in which the degree of shock is 
marked, the efforts to revive can easily be overdone in the 
matter of temperature of the hot-water bag with a sub- 
sequent further complication of the case from a bad body 
burn. As a general rule, it is safest to never put a bag 
directly against the patient's body, but to place it outside 
the blanket. 

Eye, ear, nose, and throat cases, besides the general 
care and watchfulness necessary, require to be observed 
for shock or hemorrhage, where, as in the case of the eye, 
serious functional injury might be done; or special symp- 
toms complained of relating to the particularsense-organ 
operated upon. 
276 



SPECIAL OPERATIONS 



277 



Operations upon the neck generally require the patient 
to assume the supine position. The chief danger is 
from accidental postoperative secondary hemorrhage, 
and this contingency may occur up to the third or fourth 
day when due to slipped ligatures. After intubation and 
tracheotomy operations the nurse must be watchful lest 
the tube becomes displaced, coughed out, or clogged by 
exudate or false membrane shreds. Rapid cyanosis or a 





Fig. 207. — Soft-rubber nasal and 
ear syringe. (J. P. C. Griffith.) 



Fig. 208. — Syringe cup to hang 
upon patient's ear to catch the drip 
when irrigating the aural canal. 



blowing-bellows action sounding through the tracheal slit 
are the signs calling for immediate correction of the diffi- 
culty, to avoid an immediate fatal termination of the 
case from total closure of wound or tube. If the trache- 
otomy tube is occluded, remove the inner tube, clean, and 
insert. If the case is one of tracheotomy with a displaced 
tube, the nurse should make no attempt at readjustment, 
but quickly should remove the tube and send for the 
surgeon. 



CHAPTER XVIII 

OPERATIONS IN PRIVATE PRACTICE 

In private practice the preparation of the patient is 
just the same and should be carried out as thoroughly 
as in a hospital. If it is not possible within twenty-four 
or thirty-six hours to make the preparation, then we 
cannot say that our attempts to obtain asepsis approach 
perfection. In emergency cases when there is not suffi- 
cient time to permit a thorough cleansing, freedom from 
sepsis is not so certain, and these cases do not cause the 
same anxiety as those that are sent to a hospital, where 
every effort to obtain complete asepsis is made. We 
must remember, in making the preparations, to make as 
little bustle and noise as possible, and to carry on the 
preparations in a quiet and cheerful manner, so as not to 
frighten the patient and family. When the surgeon and 
his assistants arrive they must be shown to a room in 
which they can change their clothing. The patient is not 
anesthetized until even-thing is in readiness. 

One difficulty which a nurse will have to encounter 
in private practice is likely to trouble her a great deal, 
inasmuch as she will find surgeons who conduct details 
of cases in a way to which she is not accustomed, and 
which may appear to her wrong, and which indeed may 
very often be crude and unscientific. In these cases she 
should not be too ready to show her superior wisdom and 
instruct the surgeon, and inform him under whom she 
278 



OPERATIONS IN PRIVATE PRACTICE 279 

received her training, because there is not the slightest 
likelihood that he will act upon her suggestions, but will 
naturally be offended. 

The directions for preparing for the operation will be 
given by the surgeon in charge. Have the temperature 




Fig. 209. — Portable operating-table set up for a vaginal operation. (Hirst.) 

at about 75 F. In some houses there may be a separate 
room for the operation, while in others the nurse will have 
to prepare the patient's bedroom. In the latter case the 
brightest end of the room must be selected for the opera- 
tion, to afford the surgeon plenty of light. A screen 
must be put up before the bed, so that the patient will 



28o SURGICAL TECHNIC 

not see the preparations. The nurse should remove from 
the room all movable furniture; sheet any large piece, as 
piano; lay oilcloths or newspapers covered with a damp 
sheet on the carpet, and pin them securely to it, and fasten 
a curtain across the window, so that the operation cannot 
be viewed from the opposite side of the street; or the 
panes may be frosted by lathering with soapsuds or 
Sapolio. The remaining furniture and window-frames 
should be washed with carbolic acid solution (i :6o), 
and on the morning of the operation should be mopped 
with a cloth wrung out of the solution. The articles 
necessary for the operation can be placed on the operating- 
table, covered with a sterile sheet, and be left outside the 
room until the patient is partly etherized, when they may 
be carried in. 

Have everything ready the night before when possible. 
If a separate room can be had, one with a northern light 
is to be preferred; and if pcssible it should be near the 
bath-room and convalescent chamber. Fill the bath- 
tub half full with I : iooo bichlorid solution for wash- 
ing pitchers, plates, wash-bowls. Unless the nurse has 
twenty-four hours' notice in which to prepare the room for 
operation, it should not be disturbed, because if swept and 
dusted immediately before the operation dust is stirred 
up and the air is so filled with germs that it would not 
be safe to open the abdomen in the room. If the nurse 
has a few days in which to prepare for the operation, all 
unnecessary furniture should be removed, the hangings 
taken down, the room thoroughly swept, and the walls 
and remaining furniture washed with carbolic acid solu- 
tion (i : 200) and exposed to the action of the sun and air 
for about twelve hours, when the windows are to be closed, 



OPERATIONS IN PRIVATE PRACTICE 



28l 



the room thoroughly dusted with a damp cloth, and not 
again disturbed. 

When the operation must be performed in the patient's 
bedroom, push the bed up in one corner. 

A word regarding the bed. If possible, it should 
be an iron bedstead with a fresh horsehair mattress 
and pillow. The tall wooden bedsteads which we so 












Fig. 210. — Bed arranged for reception of patient: A trough is made 
under the blanket by hot- water bags on either side. A towel is pinned to 
the lower blanket under the patient's head. (Hirst.) 

often find are perhaps heirlooms which have witnessed 
every illness that has visited the family, and also the 
deaths. They cannot be disinfected so thoroughly as can 
iron bedsteads. 

The operating-table should not be wider than 25 inches 
nor higher than 37 inches, because if low and wide the 
surgeon will have to stoop and bend forward. A kitchen- 



282 



SURGICAL TECHNIC 



table, or a dining-rccm table with the leaves hanging, and 
a small table at one end for the patient's head, or two 
dressing-tables, one placed across the head of the other, 




Fig. 211. — Kitchen table prepared for gynecologic operation, showing 
Kelly draining-pad and leg supports. (Hirst.) 



will make a good narrow operating-table; or three chairs, 
with two planks; a leaf from an extension-table, or an 
ironing board laid across them, may suffice. 



OPERATIONS IN PRIVATE PRACTICE 283 

A word of caution here: The nurse should not use 
any old blanket or comforter to cover the operating- 
table, for it is likely to be filled with germs. The top 
cover may be rubber bedcloth, oilcloth, or folded sheet, 
tied to the table by means of a muslin bandage. A Kelly 
pad may be improvised by means of a blanket rolled 
army fashion and covered with a piece of rubber cloth. 

A square-backed wooden chair should be at hand in case 
the Trendelenburg position is necessary, and two wooden 




i 

Fig. 212. — The Trendelenburg posture in bed, using a chair to elevate 
the pelvis. (DeLee.) 

boxes for the surgeon to stand upon when using this 
posture. 

An easier method is to elevate one end of the table 
upon a box. 

The lithotomy position can be quickly obtained by 
using a well-padded cane or broom handle placed under 
the patient's knees and bound in place by means of a 
twisted sheet passed around the patient's neck, over one 
shoulder, beneath the other. 

Improvise a sterilizer for instruments and dressings 



284 



SURGICAL TECHNIC 



by using a wash-boiler fitted with a light wood inside 
crate to hold the dressings above the water. Steril- 
ize glass tips and syringe bags by placing in a towel 
hammock or muslin sling hung from the handle of the 
boiler. 

The evening before the operation the nurse should boil 
a wash-boilerful of water and then fill covered pitchers, 
the wash-boiler and pitchers having first been made 




Fig. 213. — Ether bed with the foot elevated. (Sanders.) 



thoroughly aseptic. The water is conveyed from the 
boiler to the pitchers by means of a perfectly clean pitcher 
or tin ladle. 

On the morning of the operation there should be steril- 
ized in the boiler or in an oven six sheets, two blankets, 
twelve towels (not new). The heat should be kept up for 
fully one hour before the operation. The dry technic, 
by which is meant the use of dry sponges and gauze, is 



OPERATIONS IN PRIVATE PRACTICE 



28 5 



usually employed in private practice. They can be 
purchased sterile at any good drug store. 

There will be needed several clean recently boiled 
basins for the various solutions, etc. Two tables will 




Fig. 214. — Household bulb-syringe. (Davidson.) 

be needed — one for the instruments, the other for the 
assistant. They should be covered with freshly washed 
and ironed sheets or towels. There will also be needed 
a pail or a wash-tub for the soiled water, a tin dish or a 




Fig. 215 . — Fountain-syringe. 

flat bake-pan for the instruments, brandy, a hypodermic 
syringe filled with the required solution, usually strych- 
nin sulphate (2V grain), a small tumbler, a Davidson or a 
fountain-syringe, table salt for salt solution, safety-pins, 



286 SURGICAL TECHNIC 

two new nail-brushes, ready for use in a I : 40 carbolic 
acid solution. Castile soap, green soap, a razor, hot-water 
bottles, two blankets, alcohol, vinegar, and matches. 
The surgeon will bring the necessary sterile dressings, 
towels, sheets, etc., in his kit with the instruments. 

The instruments are to be wrapped in a towel and 
allowed to boil for ten minutes in a saucepan, tin pail, 
or a fish-kettle of boiling water, to which have been added 
two teaspoonfuls of washing-soda to each pint of water, to 
prevent rusting. The pail of water should be on the fire 
and the water boiling when the surgeon arrives, so that the 
instruments can be put in at once. 

If the nurse is asked to give the anesthetic she should 
not attempt anything else. None but novices give 
the anesthetic and watch the operation. The ex- 
perienced anesthetizer constantly watches the patient. 
If the nurse is asked to assist the surgeon, she must be 
neither too enthusiastic nor too quick nor too slow. 
She must see the patient safely out of the anesthetic 
influence and earn- the case along as she would any 
other. 

Sometimes a nurse is called to an emergency operation 
in a very poor family, where there are no conveniences. 
In such instances the kitchen can be cleaned and pre- 
pared as an operating-room in a few minutes. If she is 
called in the night and goes to the case with the surgeon, 
she should, while the surgeon is making his examination 
of the patient, start a fire and put on the wash-boiler, to 
make sure of plenty of boiling water. She should then 
get six sheets and twelve towels, if possible. There may 
be no clean towels, and the nurse will have to wash some 
dirty ones. The sheets and towels can be soaked first in 



Operations in private practice 287 

boiling water and afterward placed in corrosive sublimate 
solution (1 : 1000) until the surgeon is ready to use them. 
Boiling water is one of the best antiseptics, as it kills 
germs. Unfortunately it cannot be used in rendering 
our hands and the field of operation aseptic, but it can 
be used in the preparation of the sheets, towels, sponges, 
and instruments. 

The kitchen should be rendered as clean as possible. 
The kitchen-table should be prepared for the operating- 
table, and there should be two small tables, one for the 
instrument tray and one for the sponges. If small tables 
cannot be had, chairs covered with a sheet or towels 
wrung out of the corrosive solution will answer the pur- 
pose. If there is no gaslight, as many lamps as can be 
obtained should be arranged near the surgeon, but not too 
near the ether, because ether is inflammable. 

To fasten a sheet gown upon the operator, fold the 
sheet to a proper length, standing in front of the sur- 
geon, so that the top of the fold is on a level with the 
axilla; draw ends up under the arms behind. Cross each 
end to the opposite shoulder and pin in front to form 
sleeves. 

Improvise a stretcher by means of two curtain poles 
passed through a folded and pinned sheet and double 
blanket. 

After the surgeon has made the examination the part 
must be shaved, washed, an enema given to clear the 
bowels, and the urine drawn. While the patient is 
being anesthetized the nurse may arrange the tables 
and sterilize a flat bake-pan or meat-pan for the instru- 
ments. If sponges have been forgotten, a clean sheet 
can be torn up and folded into flat sponges. China 



288 SURGICAL TECHNIC 

basins can be used for the antiseptics, the sponges, and 
the surgeon's hands; china pitchers for hot and cold 
water; a wash-tub for the soiled water; and hot bricks, 
plates, stove-lids, bags of salt or beer bottles for heaters. 

Cool boiling sterile water for immediate use during 
operation by pouring out in pitchers, which are then 
to be set in vessels containing ice-water and cracked 
ice. 

In cases of contagious diseases, place all cleaning 
cloths and left-over dressings in paper bags or news- 
paper cornucopias to burn. 



CHAPTER XIX 

GYNECOLOGIC EXAMINATIONS AND 
OPERATIONS 

Perfect asepsis is of special importance in gyne- 
cologic examinations and operations, because in many 
instances the peritoneal cavity, which is highly suscep- 
tible to septic influences, is invaded by them. We must 
bear in mind that the whole genital tract communi- 
cates directly with the peritoneum, and infection at 
any point may cause peritoneal sepsis. Infection has 
taken place through the introduction of a dirty sound, 
and fatal peritonitis has followed perineorrhaphy and 
trachelorrhaphy. 

. The technic for major operations is usually perfect, 
but for minor operations carelessness is liable to creep 
in. We have no right to expose a patient to danger 
no matter how small the operation to be performed; 
and if our technic is not as perfect as we can make it 
with the means at our command, then we expose the 
patient to the greatest of all dangers, that of peritoneal 
sepsis, which usually means death. Success in surgery 
is due to minute attention to a careful technic, and a 
careless nurse may be the means of introducing sepsis, 
which may result in death after a most brilliant and 
skilfully performed operation. The most skilful surgeon 
is dependent upon his assistants for the perfection of his 
technic, and only those nurses who have been thoroughly 
instructed in the practice of asepsis and antisepsis should 
19 289 



29O SURGICAL TECHNIC 

be allowed to assist at an operation or examination, how- 
ever small. 

GYNECOLOGIC EXAMINATIONS 
The positions which a patient may occupy when under- 
going an examination are the knee-chest, dorsal, Sims, 
and the upright. 




Fig. 216, — Examination in the erect posture. (Hirst.) 

The upright, or the erect, position is rarely used for 
the purpose of making a diagnosis, but is sometimes 
preferred in verifying a diagnosis, especially that of 



GYNECOLOGIC EXAMINATIONS AND OPERATIONS 29 1 

uterine displacement, previously made with the patient 
in another position. Around the waist is pinned a sheet 
which extends to the floor, under which the clothing of 
the patient is drawn up. The patient stands with limbs 
separated, one foot resting on a stool or the rung of a 
chair. 

Dorsal Position. — The patient lies on her back with 
the knees drawn up and separated; the hips are brought 
down near the edge of the table. The heels are placed 
in foot-rests which extend out from the table about 8 
inches. A sheet having an oval slit in the center long 




Fig. 217. — Dorsal recumbent posture. 



and wide enough to expose the parts is thrown over the 
patient. In this position there is naturally a certain 
amount of flexion of the pelvis upon the trunk, and 
almost complete relaxation of the abdominal muscles is 
secured. 

Sims , Position (also called the Later o-abdominal Posi- 
tion). — In the Sims position the patient lies on the left 
side of her chest, with her head and left cheek resting on 
a low pillow, and the left arm is drawn behind the body 
or hangs over the edge of the table. The hips are brought 
down to the left-hand corner of the table, so that her 
body lies diagonally across it, the head and shoulders be- 



292 



SURGICAL TECHNIC 



ing at the right-hand side, with the left hand and arm 
hanging over the table-edge. The thighs are flexed upon 




Fig. 218. — Sims' posture, anterior view. 

the abdomen, the right thigh being so flexed that it lies 
just above the left knee, and the feet rest upon the right- 
hand corner of the table. 
This position is one in which 
there is a tendency for the 
intestines to ascend, and this 
causes the vagina to be filled 
with air and thus brings the 
uterine cervix within easy 
reach. 

The lithotomy position is 
used when operating upon the 
rectum and in some conditions 
of the bladder. The position 
is obtained by placing the pa- 
tient upon her back, knees and 
thighs flexed and separated, 
the feet being held in stir- 
rups, as seen in the diagram. 
The knee-chest, or genupectoral, position is used for 
inspection of the rectum, bladder, vagina, and cervix of 




Fig. 219. — Edebohls' dorsal pos- 
ture (lithotomy position). 



GYNECOLOGIC EXAMINATIONS AND OPERATIONS 293 



the uterus. In some cases of displacement of the uterus 
the patient may have to take this position many times 




Fig. 220.— Knee-chest or genupectoral posture, 
daily. The patient first kneels on the edge of the table 
or bed, then bends forward and rests her chest on a low 
pillow, her head lying just beyond, so that her back slopes 
down evenly, her arms clasp- 
ing the sides of the table. In 
this position the abdominal 
organs are thrown toward 
" the diaphragm ; the air enters 
the vagina and balloons it 
out, so to speak, so that there 

is an unobstructed view of 

the canal and the cervix. 
The Walcher position for 

increasing the size of the 

outlet of the pelvis during 

childbirth ; action is secured 

by means of elastic and body 

weight extension. Seldom 

used. 

Examination of the Rectum.— The patient is usually 
placed in the Sims position. Either the rectal speculum, 
or in its absence a Sims speculum (small blade), is used. 




Fig. 221.— Walcher posture. 



294 SURGICAL TECHNIC 

When the instrument is introduced the rectum becomes 
distended with air so that its walls are well exposed. If 
the patient is not in such a position that the buttocks 
are in a good light, a head-mirror, or an electric headlight 
may be needed. It is well to have these at hand in case 
they should be called for. 

For an examination of the bladder the knee-chest 
position is sometimes used; though, as a rule, the dorsal 
position is chosen, with the hips elevated high above the 
abdomen by means of cushions or pillows, which allows 
the intestines to gravitate toward the chest; and when 
the urethra is opened the bladder becomes distended 
with air and its interior is thus easily seen. Sometimes 
the patient is anesthetized for the examination, but local 
anesthesia of the urethra is usually sufficient. 

Preparation for Gynecologic Examination. — To prepare 
a patient for examination the genital parts should be 
cleansed, so that there will be no danger of carrying sep- 
tic material to the upper part of the genital tract; the 
bladder and bowels should be emptied. The uterus lies 
between the bladder and the rectum, and the distention 
of either of these organs will alter the position of the 
uterus. As a rule, no douche should be given before the 
examination, since the surgeon may want to see the 
character of the discharge. All bands around the waist 
must be loosened, also the corsets; a single tight band 
around the waist will crowd down the contents of the 
abdomen and displace the uterus. Around the patient 
is thrown a sheet, beneath which she can raise her cloth- 
ing above the waist, and then step upon a chair and 
thence to the examining-table without there being the 
slightest exposure. 



GYNECOLOGIC EXAMINATIONS AND OPERATIONS 295 

For examination in private practice, the patient is 
usually placed transversely across the bed with each foot 
on a chair and the buttock drawn well down to the edge 
of the bed. The legs and thighs should be draped with 
sheets. The usual requirements are: pair of rubber 
gloves, sterile vaselin, vaginal speculum, uterine forceps, 
and tenaculum. 

The speculum should be warmed by placing it in the 
warm sterile water. The same aseptic precautions are 
used during an examination as during an operation. 
The instruments should be sterilized. Sometimes a 
cleansing douche of corrosive sublimate (i : 2000) is 
administered after an examination. 

PREPARATION FOR OPERATION 

The preparation for gynecologic operations, such as 
perineorrhaphy, etc., are the same as for an abdominal 
operation, excepting the difference of the field of opera- 
tion to be prepared. In case the operation is a minor 
one upon the uterus or vagina, the preparations may be 
somewhat modified according to the individual preference 
of the operator, but the general rules of asepsis are always 
the same; and they must be the more strictly observed 
in these operations because the dangers of infection are 
increased by our inability to get the genital tract thor- 
oughly clean. In abdominal surgery there is not this 
difficulty. 

The preparation of a patient in a private house for 
a minor gynecologic operation should be as thorough as 
in a hospital. If the operation is to be performed with 
the patient in bed, there will be needed a wide board 
or an ironing-board for insertion between the mattress 



296 



SURGICAL TECHNIC 



and sheet, thus making a hard surface for the patient to 
lie upon. 

A piece of rubber cloth or oilcloth will serve for a 
Kelly pad. The material used is folded at the top and 
sides, covered with a towel, and the unfolded end draped 
into a pail or wash-tub. When the patient is anesthet- 
ized the bed is turned toward the window to afford the 
surgeon a good light — a northern light if possible. A bay 
window should be avoided, because it gives cross-lights. 




Fig. 222. — Trendelenburg position. (Ashton.) 



The limbs are flexed, the hips brought to the edge of 
the bed, and the Kelly pad placed under them, so that 
the water used in bathing the external parts is conducted 
by the cloth into the pail or tub. When holding the 
patient's limbs the nurse should let the heel of one foot 
rest in the palm of her hand ; the knee of the patient will 
then rest against the chest of the nurse, whose free hand 
is passed over and holds the other limb in position at the 
knee. If the nurse is asked to hold the speculum, she 
should grasp the handle from below with her right hand ; 
the angle of the speculum will thus lie in the hollow 
between the thumb and forefinger, and the convexity of 



GYNECOLOGIC EXAMINATIONS AND OPERATIONS 297 

the blade will rest on the dorsum of the hand. The upper 
labia are raised by the left hand. If the speculum or 
regular retractors cannot be obtained in the emergency, 
retractors can be improvised by bending the handles of 
four large spoons to the appropriate angle. Two are 
used to retract the lateral walls, the other two being ap- 
plied to the anterior and posterior parts of the vagina. 

After-care. — After a vaginal operation (trachelor- 
rhaphy) the patient will probably be catheterized for 
a few days. We must always remember the risk of 
cystitis. Many patients have fully recovered from the 
operation proper, but convalescence has been delayed 
by this complication. 

After passing the catheter the nurse should be care- 
ful that when removing it the urine does not drop 
on the stitches ; the parts are afterward sprayed with the 
ordered solution and dried. When giving douches the 
nurse must insert the tube carefully away from the 
stitches, and after the douche is over she should separate 
the labia and wipe the vagina dry with sterilized cotton 
or gauze held in dressing-forceps. The same care must 
be used when giving enemas, in order that the rectal and 
vaginal stitches be not broken by the tube. The patient 
must be instructed not to strain when the bowels are 
moved or the stitches may break. When dressings are 
applied they may require frequent changing in order to 
keep them clean and free from discharges. Strict antisep- 
sis must be observed, the genital parts must be kept 
perfectly clean, otherwise septic material will readily 
find access and probably result in infection of the 
wound and suppuration, or a stitch abscess. If the 
uterus is packed with gauze, the pulse and temperature 



298 SURGICAL TECHNIC 

are usually taken every two hours; and should the tem- 
perature rise to 101 F. the packing is removed. 

Diet. — A liquid diet is usually ordered until after the 
third day, when the bowels will have been moved; after 
which, if all is well, the amount of food is increased until 
it attains its customary proportions. 

The patient is generally kept in bed two weeks, and 
the sutures removed on the ninth day in the order in 
which they were introduced. After the removal of the 
stitches many operators order a vaginal douche two or 
three times a day, the amount of water varying from 2 to 
4 quarts. This treatment is successful only when the 
douches are given at the proper time and temperature. 



CHAPTER XX 

DIET RECIPES 

From the following carefully prepared and long- 
used foods for the sick the nurse will be enabled to quickly 
choose a change of diet from day to day, enabling her to 
secure the fresh, dainty daily surprise for her. patient: 

Water. — -Boiled water is the safest and best for the 
sick. Reaerated by pouring out in flat receptacle. It 
may be cooled by keeping in ordinary milk bottles set 
on ice. 

Albumin Water. — Beat up the white of one egg ; strain 
through a cloth ; add a glass of water. Stir in a teaspoon- 
ful of lemon juice, one of sugar, and a, pinch of salt. Serve 
set in a bowl of craoked ice. 

Apple Water. — Bake two apples soft, mash; pour 
a cup of boiling water over the mass; cool; strain; 
sweeten to taste. Serve with shaved ice, or set in a bowl 
of cracked ice. 

Lime Water. — Take a lump of unslaked lime the size 
of an egg, and place it in f-gallon bottle of pure cold 
water. Keep the bottle corked; after a few moments 
the lime water is ready for use, the clear liquid being 
poured off as needed. So long as any lime remains the 
bottle may be restocked by the mere addition of cold 
water. 

Barley Water. — Stir 2 ounces of pearl barley in 1 J pints 
of cold water; boil for half an hour over a slow fire in a 

299 



300 SURGICAL TECHXIC 

covered vessel; strain. Add thin cuts of lemon, or pieces 
of sugar rubbed over the lemon to flavor. 

Lemonade. — Cut a lemon in half after rolling; squeeze 
one-half into a glass, removing the seeds; add a little 
water and stir in a heaping dessertspoonful of sugar. 
Fill up the glass with waiter; stir in more sugar if neces- 
sary. 

Effervescing Lemonade. — Add half a teaspoonful of 
bicarbonate of soda to the above, or Vichy water may 
be used. 

Egg Lemonade. — Shake up the white of one egg in a 
cup of water, to which add two teaspoonfuls of lemon 
juice and sugar; shake. Serve at once. 

Imperial Drink. — Add a teaspoonful of cream of tartar 
to I pint of boiling water; squeeze and add the juice of 
half a lemon; add a dessertspoonful of sugar. Serve 
cold. 

Tamarind Water. — Stir a tablespoonful of preserved 
tamarinds up in a cupful of boiling water; allow to cool; 
strain. Serve with shaved ice. 

Currant Juice. — To a tablespoonful of currant jelly 
add a cupful of boiling water, stirring; sweeten to taste; 
set aside to cool. Serve with ice. 

Orangeade.- — Peel an orange; pour a cupful of boil- 
ing water over the peeling; squeeze and add the juice 
of the orange and a dessertspoonful of sugar; let cool; 
strain. Serve cold with shaved ice. A teaspoonful of 
lemon juice may be added to vary the taste. 

Milk Diet. — This consists of 2 or 3 quarts of milk 
daily. 

Koumiss. — Dissolve a third of a cake of compressed 
yeast in a little lukewarm water; add this to I quart of 



DIET RECEPES 301 

fresh, warm milk; stir in a tablespoonful of sugar. Put 
the mixture in stoppered bottles; cork and set away for 
twelve hours in a temperature of about 70 F. Then 
put the bottles upside down on ice until ready for use. 

Toast Water. — Remove the crust from a slice of stale 
bread; toast without burning. Break the slice up and 
put the fragments into a small crock or pitcher; add a 
couple of pieces of orange peel or lemon. Pour over all 
I pint of boiling water; cover with a napkin; let cool; 
strain for use. Must be made fresh. 

Toast Soup. — Toast a thin slice of stale bread. While 
hot spread butter over it, having no excess. Break 
into fragments and place in a pitcher ; add j pint of boil- 
ing water; add a pinch of salt and pepper. Serve hot. 

Flaxseed Tea. — Add one-half cup of flaxseed to 1 quart 
of boiling water. Boil for one-half hour over a slow 
fire. Allow to set near the fire for fifteen or twenty 
minutes; add a teaspoonful of lemon juice; sweeten to 
taste; strain. Serve hot or cold. 

Slippery elm bark may be added to the above mixture, 
allowing \ ounce of the bark to 1 pint of liquid. 

Milk and Cinnamon. — To \ pint of new milk add enough 
broken cinnamon sticks to flavor ; add to this a teaspoon- 
ful of sugar; strain. Serve cold or hot. 

Arrowroot Gruel.— Stir up half a tablespoonful of 
arrowroot flour with a little cold water; add a cupful of 
water, stirring in half a dessertspoonful of sugar and a 
pinch of salt. Boil slowly for twenty minutes, stirring 
constantly; add a cupful of milk; boil; strain. Serve 
hot. 

Barley Gruel. — Stir up a tablespoonful of barley flour 
in a little water; add a cupful of water in which has 



302 SURGICAL TECHNIC 

been mixed halt a dessertspoonful of sugar and a pinch 
of salt; heat; bring to a boil, continuing it for twenty 
minutes: stir constantly: add a cupful of milk; bring to 
a boil: strain. Serve hot. 

Cracker Gruel. — Dissolve half a teaspoonful of sugar 
and a pinch of salt in a cupful of water: apply heat. 
Mix up two tablespoonfuls of grated cracker in a little 
water and add to the heated water. Boil for rive min- 
utes: add a cupful of milk and again bring to a boil. 
Serve hot. 

Flour Ball. — Tie up half a pint of flour in a square of 
cheese-cloth very tight: place in a pot of boiling water; 
cook for five hours. After removing the cloth peel the 
outside of the ball and grate; dry in the oven and keep 
in a closed jar. This may be used for making gruels; 
also to dilute milk for young children. 

Tapioca Jelly. — Soak a cupful of tapioca for two hours: 
when soft, place in a saucepan: add a dessertspoonful 
of sugar; the rind and juice of one lemon: a pinch of 
salt and I pint of water; heat, stirring the mixture 
until boiling: turn into a mold and set out to cool 
before serving. 

Tapioca Soup. — Boil I pint of meat broth: stir in I 
ounce of washed tapioca. Set on the back of the stove to 
simmer, covering the vessel. Skim and serve hot. 

Eggs. — Boil eggs by dropping them into boiling water. 
and continue for three minutes. 

Poached Eggs. — Bring water to a boil in a saucepan; 
add a pinch of salt: slip the egg carefully broken in a 
saucer into the salted water. Cook until the white is 
firm but jelly-like: remove with a skimmer and serve on a 
thin piece of buttered toast: sprinkle a little salt and 



DIET RECIPES 303 

pepper on the top; garnish with parsley sprig. Serve 
at once. 

Scrambled Eggs. — Beat up two eggs thoroughly; add 
two tablespoonfuls of milk; a pinch of salt. Pour into a 
very hot buttered frying pan; stir constantly for about 
two minutes. Serve on buttered toast at once. 

Shirred Eggs. — Heat up the shirring cups. Put in 
each cup a bit of butter; break into each an egg. Allow 
to remain on the stove for a moment, then serve hot in 
the cup, adding a pinch of salt. 

Panado. — Take a slice of wheat bread and break up 
into fragments; sprinkle a teaspoonful of ground cinna- 
mon over the whole ; add I pint of boiling water ; boil for 
five minutes; add a teaspoonful of sugar and a little 
grated nutmeg. Serve hot. 

Milk Toast. — Prepare two slices of crisp toast. Heat 
a cup and a half of milk to the boiling-point ; add a pinch 
of salt and a small bit of butter. Pour the milk mixture 
over the toast in a closed dish. Serve hot. 

Rennet. — One pint of warmed milk, sweetened, and 
flavored with nutmeg, cinnamon, or lemon; add one large 
teaspoonful of liquid rennet; stir for one minute; set 
aside to cool and set. Serve with sugar and cream. 

Boiled Rice. — Rice must continue to boil until every 
grain is softened without dissolving into a shapeless 
mass. 

Plain Rice. — Two tablespoonfuls of rice are to be 
washed and placed in a shallow baking dish; add two 
tablespoonfuls of sugar ; flavor with lemon peel or vanilla ; 
add 1 quart of milk. Bake for three hours in a moderate 
oven, stirring every twenty minutes. Cool for an hour 
before using. Serve cold. 



304 SURGICAL TECHNIC 

Tapioca Pudding, — Soak one-half cup of tapioca over 
night in cold water ; put it over the fire and heat to clear- 
ness. Mix up I pint of milk and two eggs to form a cus- 
tard by heating the mixture until almost boiling, then stir 
in two tablespoonfuls of sugar and cook for three minutes 
in a double boiler, stirring gently all the time. When 
done it should be as thick as cream. If allowed to cook 
too much it separates and is spoiled. Add the milk 
custard to the tapioca ; sweeten and flavor to taste ; bake 
in a quick oven. Set aside to cool. Serve cold. 

Cornstarch. — To one tablespoonful of cornstarch add 
cold water enough to make a smooth paste. Add to this 
| pint of milk; boil for five minutes, stirring all the time; 
add a pinch of salt; sweeten to teste, and add a flavoring 
extract. Serve cold. 

Beef Essence. — Cut up I pound of fresh lean beef 
into small pieces; sprinkle a little salt over the mass; 
place the cut-up meat into a stout stone jug; place the 
jug in a vessel of cold water and bring to a boil; cork the 
jug tightly when steam begins to issue from the mouth. 
Continue boiling for at least four hours; strain through 
a cloth and season the meat juice obtained with pepper 
and salt to taste. 

Invalid's Soup. — To I pint of beef essence made quite 
hot add \ pint of cream, likewise hot, to which the yolk 
of a fresh egg has been stirred. Mix carefully together 
in a lined saucepan; season and serve . 

Beef Broth.— Take i pound of beef (neck or shoulder) 
and slice it up; place in a pan and salt, then pour on I 
quart of cold water; place on the fire and bring to a sim- 
mer ; keep so over a slow fire for an hour and a half ; set 
back on the range for half an hour; strain; serve. 



DIET RECIPES 305 

Mutton Broth. — Cut up i pound of good mutton into 
small pieces and sprinkle with salt; allow to simmer over 
a slow fire, after adding I quart of cold water, for an 
hour and a half; boil for half an hour; strain; serve. 

Beef Juice. — Take f pound of lean beef and cut it 
up in pieces of about the size of a pigeon's egg; toast the 
pieces over hot coals; squeeze out the juice with a meat 
presser or lemon squeezer; add a pinch of salt before 
serving. 

L ; Chicken Broth. — Take a small chicken, removing skin 
and fat between the muscles; divide it in two down the 
back ; remove the lungs as well as everything adhering to 
the side- bones and back; cut up the halves in thin slices; 
place them in a pan and sprinkle with salt, then add I 
quart of cold water; bring to a simmer over a slow fire; 
allow to remain for an hour and a half. Then remove 
from the fire to a place where the heat will still be kept 
up for half an hour longer ; strain ; serve hot. During the 
cooking a sprig of celery may be added, or a clove, or half 
a dozen pepper-corns to give it a flavor. 



CHAPTER XXI 

SIGNS OF DEATH; AUTOPSIES 

Winslow, one of the professors at the University of 
Paris, and who had twice been taken for dead, was the 
first to make a scientific investigation of the signs of 
death. After Winslow came Louis, and since their time 
eminent men, especially in countries prescribing rapid 
burial, have endeavored to find certain and reliable signs 
of death before decomposition begins. 

SIGNS OF DEATH 
Absence of respiration is not a sure sign of death, as 
it may be due to syncope or to the person being in a 




Fig. 223. — Stethoscope. 

trance; nor is absence of the heart-beat, unless deter- 
mined by means of a stethoscope in experienced hands. 
Coldness and rigidity may be due to collapse or catalepsy 
or in persons who are frozen stiff. 

In doubtful cases of apparent death which occur sud- 
denly or from external violence the following tests are 
usually applied: 
306 



signs of death; autopsies 307 

1. The absence of the heart's action is carefully deter- 
mined by a stethoscope or phonendoscope. 

2. Absence of the circulation is ascertained by tying 
a string tightly around a finger or a toe ; if the tip becomes 
blue, life is not extinct, though this may occur in cases 
where there has been great loss of blood, and in other 
cases where the heart is too weak to send the arterial 
blood into the capillaries of the fingers. 

3. Absence of respiration is determined by placing 
the surface of a mirror before the mouth; if the surface 
becomes moist, respiration has not ceased. 

4. If a subcutaneous injection of aqua ammonia is 
given a red or purple spot will form if life still exists. 

5. If a needle is inserted into the flesh of a living per- 
son blood will escape, but not if life is extinct; still, if 
there has been a large loss of blood there will be no es- 
cape of blood in the living. 

Rigor mortis (postmortem rigidity or stiffness of 
death) begins in the upper part of the body, usually in 
the maxillary muscles, and spreads gradually from above 
downward. It disappears in the same order. It comes 
and goes quickly after great muscular effort or excite- 
ment, and when once it has been broken up it does not 
return. The time it sets in after death varies from ten 
minutes to twelve or even twenty-four hours. Rigor 
mortis is considered the most positive sign of death, be- 
cause it indicates death of the muscle itself. 

Death of the body as a whole takes place first, and at 
intervals of an hour or even several hours death of one or 
other of the involuntary muscles follows. 

Hypostasis, cadaveric lividity, or congestion of blood 
in the capillaries, which forms in all the dependent parts 



308 SURGICAL TECHXIC 

of the body, is considered a valuable sign of death, but 
this purple color may be due to contusion, and has been 
seen in cholera patients before death. 

The body temperature at and from one to two hours 
after death may be very high, 107 or 112 F. Patients 
dying from cholera and yellow fever have high tempera- 
tures for several hours after death; but, as a rule, the 
body is cold to the touch in from six to ten hours. 

AUTOPSIES 

Every nurse should do all in her power to assist the 
physician or surgeon to obtain autopsies, and with a little 
tact the necessary permission can usually be obtained. 
Every well-conducted autopsy adds more or less to medi- 
cal knowledge. It verifies the diagnosis of the illness, 
and in many cases it explains or shows the cause of symp- 
toms the explanation of which could not be determined 
before death. In surgical work, when a patient dies in 
less than twelve or fourteen hours after an operation, the 
autopsy, when made by a competent bacteriologist and 
pathologist, will show whether death was due to sepsis or 
to some organic disease over which the surgeon had no 
control. 

In a private house the autopsy should be held in the 
room giving the best light, and if possible in the day- 
time, in order to obtain the correct color-interpretation, 
for if made in artificial light the observations will not be 
entirely trustworthy. 

At the present time an autopsy is preferably held al- 
most immediately after death and before putrefactive 
changes have taken place. The undertaker should al- 
ways be warned not to inject the body, because the fluids 



signs of death; autopsies 309 

usually employed, which contain among other things 
corrosive sublimate and arsenic in large quantities, 
change the color and consistency of the organs to such an 
extent that it is difficult to recognize the pathologic 
processes. Then, again, the punctures made during the 
embalming process may open an abscess or other cavity 
and thus distribute the contained pus or exudates. 
Embalming fluid has been poured into the mouth, and 
having found its way into the lungs and stomach has 
greatly changed the appearance of those organs. 

The clothing on the body should be removed and 
a large sheet spread over it; or if preferred, a night-dress 
or skirt open down the middle may be put on. 

If the corpse is female, braid the hair in two plaits after 
combing a part extending from ear to ear over the crown. 
Coil each plait securely with hair-pins. 

The things a nurse should provide are : 

1. Large rubber sheet, old oil-cloth, old quilts, or 
papers to put under trestle to protect the floor. 

2. Small table for instruments. 

3. Three wash-bowls: one for corrosive sublimate, one 
for dirty instruments, and one for the organs removed. 

4. Two pails for dirty water. 

5. Old towels and a number of old sponges. 

6. Plenty of hot and cold water. 

7. About 4 quarts of fine sawdust, or oakum, or excel- 
sior packing, absorbent cotton, or common cotton for 
filling up cavities, any one of which will prevent fluid 
oozing through the incisions. When these are not ob- 
tainable, bran, cloth, or newspapers may be used. Fine 
sawdust is the best material, as it packs easily, does not 
interfere with the sewing by getting into the stitches, and 
keeps the needle dry. 



3IO SURGICAL TECHNIC 

8. Six wide-mouthed bottles in which to place speci- 
- from the various organs, and which can be securely 

corked. 

9. About 3 yards of fine twine or carpet- thread, and a 
large darning-needle or a large curved needle. 

Should the autopsy take place in a house where there 
are no conveniences, the body can be left lying on the 
undertaker's stretcher covered with a sheet, the clothing 
removed, and a large napkin put on. There should be 
several old newspapers to protect the floor, and on which 
to place the dirty instruments and organs removed; an 
old sheet, a pail, a wash-bowl, and a pitcher of warm water 
can always be obtained. 

The sheet is torn into four pieces. Two pieces are 
used, one for each side of the neck and trunk, covering 
the arms, leaving the chest and abdomen free for the 
surgeon to operate: the third piece is placed beneath the 
head : and the fourth piece is tucked in below the genitals, 
rovering the lower extremities. The bowl contains 
the large dampened sponge, and. together with the pail, 
should be placed within convenient reach. 

Absolute cleanliness is essential at a private autopsy. 
Blood-stair s must be washed from the walls, floor, dishes. 
the rubber or oil-cloth : the papers, eld sponges, and cloths 
should be burned, and the body must be washed perfectly 
clean. The room must be left in perfect order — just 
as it was before the postmortem. Ground coffee thrown 
on a few live coals will remove all odor from the room. 

For removing the odor from the hands, turpentine 

will be found serviceable, or a solution of permanganate 

of potassium and oxalic acid, or a dilute solution of 

formaldehyd. The result of the autopsy must be kept 

vealed to no one. 



CHAPTER XXII 

HYGIENE; PERSONAL CONDUCT OF A NURSE'S 
LIFE; OF THE REWARDS; SUCCESS 

The care of her own person must not be forgotten by 
the aspiring nurse, else she may gain the coveted post of 
trusted helper to physicians at the price of loss of her 
bodily health. Rest and regularity in conducting her 
mode of life are the chief factors for securing a continu- 
ation of sound health which every nurse should possess 
who attempts the work of caring for the sick. Futile 
as it may seem to suggest rest and regularity to one 
whose professional life is largely made up of activity 
and irregularity of mode of personal life, it is neverthe- 
less essential for a good nurse to learn how to save up 
energy during ordinary times that she may have suffi- 
cient vital capital force to meet the emergency demands. 

Sufficient sleep and a regular time for eating is as im- 
portant for the well as the sick, and in the matter of 
eating it must be recalled that a mouthful of food which 
has been well masticated before swallowing will give 
much greater return in energy than many of the hurried 
mouthfuls which nurses are too prone to take. 

Attention to the calls for emptying of the bladder and 
the bowels are for the most part made a matter of con- 
venience rather than considered as most important 
functional activities to be attended to without delay. 

Daily stimulation of the skin of the entire body by 
bathing, even if but a sponge-bath taken from a wash- 

311 



312 SURGICAL TECHNIC 

bowl or a basin, is to be recommended, for while the 
average nurse may be forced to scrub her hands and arms 
too often for either health or comfort, there is seldom al- 
lowed time enough for sufficient body bathing. 

The presence of decayed teeth, corns, bunions, varicose 
veins in the legs, and hemorrhoids are all common affec- 
tions which may be borne a long time, but the nurse 
who has such things may come to a time of final failure 
in her professional career. Upon the very first appear- 
ance of the handicapping conditions mentioned she must 
seek relief, for the best that medical and surgical advice 
and treatment can give is hers by right. Aside from the 
ordinary affections which arise from ill-fitting shoes, 
nurses are particularly liable to the condition called 
"foot-sore," student nurses being special sufferers. While 
the hard floors of modern hospitals are responsible for 
the condition during the earliest days of a nursing 
career, later its control is a matter of proper care of 
the feet themselves. A nurse must seek foot comfort 
and health, not by wearing her oldest, run-down shoes, 
but a well-fitting, ample-sized shoe which allows her 
toes to lie uncramped. The other essential for com- 
fort is to keep the feet dry*. Perspiration quickly 
softens the skin of the feet, and allows swelling in the 
soft cellular tissue beneath to take place. While a per- 
spiring foot is by no means unhealthy, the relaxation 
which accompanies it calls for treatment. To overcome 
the effects of excess the following measures will be found 
useful: A daily change of shoes: one or more changes of 
stockings during the day; stimulating foot-baths, alter- 
nating hot and cold water, accompanied by rubbing 
with a coarse towel and massage; alcohol bath and rub; 



hygiene; personal conduct of a nurse's life 313 

painting the soles of the feet with a 10 to 20 per cent, 
formalin solution once or twice a week; talcum powder, 
rice flour, fuller's earth dusted in the shoes will be found 
invaluable in keeping the feet both dry and warm. A 
daily change may be made at the time of dressing. In 
general, high laced shoes with low heels will prove more 
comfortable than the low light-weight ties. Rubber 
heels are restful, as they greatly reduce body- jarring. 
Tendency to flattening of the arches of the feet, mani- 
fested by a continuous ache upon standing, may be over- 
come by massage, strapping, and bandaging, or sup- 
ported by sole-plates. 

The continual scrubbing and immersions in the various 
antiseptic solutions of hands and arms which the modern 
nurse is compelled to undergo often gives rise to discom- 
fort, if not to well-marked skin disease. Drying up of 
the normal oil of the skin is the earliest direct cause of 
roughness, cracking, and scaling skin. There is a pecu- 
liar sensitiveness of certain individuals' skins for such 
drug solutions as carbolic acid, bichlorid of mercury, 
and oxalic acid, which act toward them as special irri- 
tants and which is known by the term "idiosyncrasy." 
In general, to keep the hands pliant by massage and the 
free use of cold cream, lanolin, or some such bland oint- 
ment will suffice. In cases which fail of relief rubber 
gloves must be worn. 

The importance of cultivating her powers of observa- 
tion can hardly be estimated, so much will the nurse's 
reliability be thereby increased. After making the first 
general observation her duty is to note changes, to see 
and jot down facts, not bias her observing faculty by 
evolving opinions. 



314 SURGICAL TECHNIC 

A gc >d nurse makes no noise herself, and acts as a per- 
petual noire preventer in and around the sick-room. 

The stricter a nurse holds herself to the prescribed 
uniform of her school the better, thus fancy collars 
and neckwear, jewelry, hair ornaments, and finger- 
rings detract her personality from the role she plays. 

The calling of a nurse demands that she be always 
neat and trim in the matters of her personal appear- 
ance and in clothing effects, and that her professional 
relationship with the patient, his family, and the physi- 
cian call for but the ordinary dignity- which becomes a 
woman" s greatest charm when least assumed. 

While the mental caliber of the successful nurse is 
from necessity large, she will do well not to continually 
tax herself with the requirements of her art. Proper 
amusements have their place, and will the better equip 
her for the serious work hours. 

Xurses will do well to study surgical supply catalogues. 
so as to know the cost of supplies and keep abreast of 
what is new. A postal request will suffice to supply her. 

X 3 matter how physically well a nurse may conduct 
her life, it becomes a necessity for her to secure a change 
of scene during a month or two of the year, which may 
be obtained by means of a " "traveling case." by connect- 
ing herself with work in some distant part of the country- 
through correspondence, or the channels of a medical 
journal's advertisement columns, or by expending part 
of her year's savings for board in the country or at the 
seashore. Every nurse's bureau should have its corre- 
spondence department to provide for this 'exchange" 
system in practice over the country. Besides rest in 
change of environment the results will be better, because 



hygiene; personal conduct of a nurses life 315 

broader, educated nurses. Of the rewards for conscien- 
tious work the nurse's outlook is a bright one, for better 
salaries are offered and more may be expected to be paid 
in the future for high-class work than ever before. The 
matter of money loss to nurses, which occurs between 
1 'cases," is to be overcome by a mutual division of ex- 
penses, as is customary in large communities. Five or 
six nurses "keep house" in a few rooms, the one who is 
professionally unemployed acting as "housekeeper." 
By this means direct communication is kept up between 
doctors and nurses. While the agency system for hiring 
nurses is good, a sure plan for a nurse to gain cases is by 
periodic personal visitations upon doctors. A nurse 
who calls upon a physician and tells him what she can do 
and the scale of her prices for her work has made an im- 
pression and she will be remembered by the doctor when 
in need of a nurse's aid. 

Individual success for the nurse, as in any other voca- 
tion, must be the sum-up of her whole life's work. If at 
the commencement of her career she learns to know her- 
self as a helper — one whose life's work is dedicated to the 
sick and to a loyal devotion to the medical profession, of 
which she is herself a most important part — such a one 
is well started in her career and is on the high road toward 
success and honor. 



GLOSSARY 



A. 

Abdominal binder. A wide band- 
age dressing used to support the walls 
of the abdomen after open operations 
or the womb after childbirth. Muslin, 
flannel, or towelling may be used, 
and is applied snugly by overlapping 
tails and fastening or by safety-pins. 

Abdominal operation. An opera- 
tion which involves opening the ab- 
dominal cavity as a preliminary. 

Abdominal section. An opera- 
tion in which the belly cavity is 
opened. 

Abscess. A circumscribed collec- 
tion of pus. 

Acetic fermentation. Souring 
with the production of acetic acid or 
vinegar. 

Actinomycosis. A disease of cattle 
which may be transmitted to man; it 
is due to the ray fungus. 

Active hyperemia. Steady in- 
crease of the quantity of blood in 
the vessels of a part. 

Acupressure. Compression of a 
blood-vessel by twisting with an in- 
serted needle. 

Acute disease. One active in on- 
set, energetic in course, and of short 
duration. 

Aerobic. Requiring the presence 
of oxygen for development. 



Albumose. A substance formed 
during the digestion of albumin. 

Alimentary canal. The digestive 
tube extending from the mouth to the 
anus. 

Alterative. A medicine having a 
gradual and general tendency toward 
the production of health. 

Anaerobic. Requiring absence of 
oxygen for growth to take place. 

Anesthetic. Producing uncon- 
sciousness to pain. 

Aneurysm. A disease of blood- 
vessels due to stretching or rupturing 
of one or more of the coats. 

Aniline derivative. An agent 
prepared from coal-tar. 

Anthrax. A contagious disease 
of cows and sheep often transmitted 
to man, due to the Anthrax bacillus. 

Antiseptic. An agent by whose 
action germs are destroyed or their 
growth prevented. 

Antiseptic agent. One which 
inhibits the growth or destroys germs. 

Antiseptic surgery. The various 
procedures which are carried out with 
the idea of preventing or destroying 
germ contamination. 

Antistreptococcic serum. A pro- 
tective blood-water taken from an 
animal which has successfully recov- 
ered from graded injections of virulent 
pus germs. 

317 



3i« 



GLOSSARY 



Antitoxin. A defensive proteid 
developed in a body for its protection 
from microbic assaults; a curative 
blood serum. 

Aqua ammonia. Ammonia-water. 

Arterioles. Smallest branching 
arteries. 

Artificial inoculation. Attempt 
to produce a disease by injection or 
local application of the germs, their 
products, or the virus producing it. 

Artificial media. An agent cap- 
able of supporting germ life outside 
of the body. 

Asepsis. Freedom from septic 
poisoning; clean. 

Aseptic. Free from germs; sterile. 

Astringent. An agent which causes 
contraction of tissues and the lessen- 
ing of secretions. 

Atomizer. An appliance for spray- 
ing. 

Aural. Pertaining to the ears. 

Aural canal. The ear passage. 

Autopsy. The examination of a 
dead body, a post mortem. 

Autopsy room. A room set aside 
for the examination of dead bodies. 

Axilla. The arm-pit. 



B. 



Bacilli. Rod-shaped germs, as 
tubercle bacilli, the cause of consump- 
tion. 

Bacteria. Minute organisms; mi- 
crobes. 

Bacteriologist. One who studies 
and experiments with germ life. 

Bacteriology. The study of germs. 

Bed heater. An appliance for 
heating a bed, as with a hot-water bag, 
hot bricks, etc. 

Beef essence. Concentrated beef 
extract. 



Bistoury. A sharp narrovv-bladed 
surgeon's knife; may be sharp or dull 
pointed; curved. 

Blastomycete. Yeast-forming 

germ. 

Blood serum. The watery portion 
of animal fluids. 

Boroglycerid. A pasty compound 
made by slowly dissolving two parts 
of boric acid in three parts of hot 
glycerin. 

Bouillon. Strained beef soup; a 
culture-medium. 

Bronchi. The first division of the 
windpipe. 

Bronchioles. The finest divisions 
of the windpipe. 

Bronchorrhea. Excessive flow of 
mucus from the windpipe. 

Bubonic plague. An acute, con- 
tagious disease characterized by a 
malignant type of fever and forma- 
tion of buboes or glandular swellings 
throughout the body. 

Buttocks. The fleshy parts back 
of the hips. 

c. 

Cancer. A morbid growth whose 
tendency is to spread and to cause 
ultimate death. 

Capillaries. The finest divisions 
of the blood-vessels. 

Capillary hemorrhage. Oozing 
of blood. 

Carcinoma. One form of cancer; 
common seat is the female breast. 

Catalepsy. Condition of partial or 
complete suspension of will and con- 
sciousness, with rigidity of voluntary 
muscles. 

Catheterization. The act of draw- 
ing off the urine. 

Catheterize. To draw off the 



GLOSSARY 



319 



Cellular tissue. Loose fatty spaces 
beneath the skin and between organs. 

Cerebrospinal fluid. Serous fluid 
contents of the cavities of the brain 
and spinal cord. 

Cervical canal. Channel in the 
neck of the womb connecting the 
vagina with the body cavity of the 
womb. 

Chemic. Chemical; relating to 
chemistry. 

Chill. A nervous symptom usu- 
ally marking the onset of disease, in 
which the patient has rigors and com- 
plains of being cold; in malarial fever 
the temperature is really highest at 
this time. 

Chlorinated soda. Soda which 
has been combined with chlorin. 

Chlor in -water. A saturated solu- 
tion of chlorin in distilled water. 

Citronella. A fragrant Asiatic 
grass from which is obtained a volatile 
oil, useful, when applied to the person, 
in driving away mosquitoes. 

Clammy. Moist and cold. 

Clamp. An instrument with de- 
tachable handles to apply to the 
broad ligament; in operations for 
removal of the uterus through the 
vagina, six or eight are applied upon 
each side. A hemostatic forceps to 
control hemorrhage from vessels that 
cannot be reached to apply ligation. 

Clostridium. A bacillus distended 
at its center by a large spore. 

Coagulable quality of blood. The 
power to clot. 

Cocainization. The act of pro- 
ducing cocain anesthesia. 

Collapse. General failure of the 
vital powers without loss of con- 
sciousness. 

Colony. A localized, unmixed 
growth of micro-organisms. 



Complication. A disease appear- 
ing during the course of another, 
which may modify the termination. 

Contagious. Capable cf being 
transmitted from one individual to 
another; catching. 

Contagious affection. A disease 
directly transmissible from one person 
to another. 

Contagious disease. One which 
may be directly transmitted from one 
to another. 

Convalescence. The period of 
uninterrupted recovery from ill- 
ness. 

Convulsion. A nervous condi- 
tion giving rise to violent, continued, 
or intermittent muscular contrac- 
tions. 

Corrosive sublimate. Bichlorid 
of mercury. 

Coryza. Cold in the head. 

Cranioclast. An obstetrical in- 
strument to aid in the delivery of a 
child's head by crushing. 

Crystalline. Colorless; clear as 
crystal. 

Culture -media. Substances upon 
which germs are experimentally 
grown. 

Cumol catgut. Catgut sterilized 
for surgeon's use by superheating in 
a solution of cumol, a product of 
coal-tar. 

Curetting of uterus. Clearing 
out of the contents of the womb or 
scraping the membranous lining of 
its cavity. 

Cyanosis. The symptoms arising 
when the supply of oxygen is greatly 
lessened, as in strangulation. 

Cyst. A circumscribed membran- 
ous cavity occurring abnormally and 
containing fluid, semifluid, or solid 
contents. 



,20 



GLOSSARY 



Cystitis. Inflammation of the 
bladder 

Cystoscopic examination A study 
of the bladder by the use of an in- 
strument which brings its surface di- 
rectly into view. 

D. 

Decomposition. Act of decaying: 
rotting; separation into elements. 

Delirium. Mental state in which 
there is a rapid flight of ideas which 
are incoherent and often unintelli- 
gible. 

Depletion. Reduction of the 

amount of fluid, as blood or serum, in 
a part. 

Diabetic coma. Loss of con- 
sciousness due to the action of poisons 
in diabetes. 

Diaphragm. The great breathing 
muscle separating the chest from the 
abdomen. 

Dilatation of cervix. Act of 
stretching the mouth and neck of the 
womb. 

Disinfectant. An agent capable 
of destroying microbes or the prod- 
ucts of their growth. 

Disinfection. The act of render- 
ing free from micro-organisms or 
their effects; purifying. 

Distillation. The act of heating 
a solid or liquid in an apparatus, so 
that the vapors given off may be 
collected. 

Douche. A more or less forcible 
flushing of a cavity or part of the body 
for purposes of cleansing and stimula- 
tion. 

E. 

Eclampsia. Convulsions during 
the childbearing period caused by 
kidney disease. 



Ecraseur. An instrument used to 
squeeze its way through tissue causing 
least amount of bleeding by employing 
a gradually tightening wire or string. 

Eczematous condition. One in 
which peeling and crusting of the skin 
occurs with more or less itchiness. 

Edema. Swelling due to excess of 
serous fluid within a tissue. 

Effervescence. Bubbling. 

Elaborated. Developed; pro- 
duced 

Electrolysis. Decomposition by 
electricity. 

Elimination. The act of throw- 
ing off; expelling. 

Emergency operation. One made 
necessary by the serious condition of 
the patient. 

Emesis. Vomiting. 

Emetic. A substance causing 

vomiting. 

Emulsion. A fluid containing fat 
suspended in very fine particles, form- 
ing an opaque, milky white mixture. 

Endocarditis. Inflammation of 
the lining membrane of the heart. 
The process is usually confined to the 
valves. 

Endometritis. Inflammation of 
the lining of the womb. 

Enemata. Rectal injections; solu- 
tions used to cleanse the lower bowel. 

Enteroclysis. The administration 
of a rectal injection. 

Epidemic. A general invasion of 
a community by a given disease. 

Epidemic cerebrospinal menin- 
gitis. A microbic disease giving rise 
to inflammation of the lining mem- 
branes of the brain and spinal cord 
with convulsions, irregular fever, and 
a rash. 

Epidermic. Injected: relating to 
the skin. 



GLOSSARY 



321 



Epidermis. The surface-covering 
of the body; the skin. 

Epithelial cells. Microscopic 

units; fiat upon the skin, goblet- 
shaped on mucous membranes, form- 
ing the surface layers of these tissues. 

Epithelium. Skin covering. 

Eruptive fever. One attended 
with a rash; scarlet fever. 

Erysipelas. An acute contagious 
skin disease caused by streptococci, 
giving rise to irregular fever, and with 
a tendency to relapse. 

Erythema. Redness of the skin; 
blushing. 

Eucalyptus. An Australian gum 
tree from which is obtained an oil 
used in medicine. This oil produces 
sweating, is tonic, stimulant, and anti- 
septic. 

Eustachian catheter. A tubular 
instrument designed to pass through 
the nasal cavity to the opening of the 
Eustachian tube. This latter is a canal 
leading from the back of the mouth to 
the middle ear. 

Evaporation. Loss of water by 
the action of heat. 

Excretions. Products of body 
waste; urine. 

External jugular vein. The larg- 
est superficial vein in the neck, run- 
ning downward midway upon both 
sides. 

F. 

Fallopian tubes. Two trumpet- 
shaped pipes, each about four inches 
long, connecting the womb with the 
abdominal cavity, through which ova 
pass. 

Fascia. Strong, glistening fibrous 
sheaths separating muscles. 

Feces. Body and food waste from 
the bowels. 

21 



Fermentation. The change ef- 
fected by the action of a ferment; 
souring. 

Fetus. A young child within or 
taken from, its mother's womb before 
it has fully developed. 

Fibrils. Thread-like connective 
tissue. 

Fibrin. Fine elastic strands formed 
during clotting and inflammation. 

Fibrin-ferment. A substance 

causing the formation of fibrin. 

Fistulae. Disease tracts indisposed 
to heal. 

Flacherie. A contagious disease 
of silkworms caused by micrococci. 

Flat wines. Wines spoiled by 
begin ning acid fermentation. 

Flatulence. Excess of gas in the 
stomach or bowels; wind colic. 

Fuller's earth. A finely powdered 
earth used as an absorbent. 

Fumigate. To free from infection 
by the use of vapors. 

Fungi. The lowest order of non- 
flowering plants living upon animal 
matter; in bacteriology, a micro-organ- 
ismal moss. 

G. 

Gangrene. Local death of the 

part. 

Germ theory. The theory that all 
specific disease is due to the presence 
or action of micro-organisms. 

Germicidal solution. A germ 
killer. 

Glanders. A disease of horses 
caused by the bacillus mallei which 
affects the air-passages and skin and 
is transmissible to man. 

Globulins. A form of albumin. 

Gonococcus. The germ that 

causes the venereal disease called 



322 



GLOSSARY 



gonorrhea; consists of a double, 
dumbbell coccus. 

Gonorrhea. A sexual disease 
caused by the transfer and activity 
of a germ called the gonococcus 
from one individual to another. 

Granulation tissue. Reddish, bud- 
like projections found upon the sur- 
face of a healing wound. 

Gynecologic. Relating to the 
sexual organs of a woman. 

H. 

Heart paralysis. A condition in 
which the heart's action is rapidly 
weakened or ceases. 

Hemorrhage. Bleeding; generally 
used to designate a profuse loss of 
blood from the vessel affected. 

Hemorrhoids. Dilated and elon- 
gated blood-vessels about the open- 
ing of the lower bowel; piles. 

Hernia. An abnormal protrusion 
of an organ or tissue. 

High enemata. An injection made 
high into the bowel by aid of gravity 
and a rectal tube. 

Hives. Common name for a skin 
disease giving rise to an evanescent 
eruption associated with severe itching. 

Hydrophobia. A disease of dogs 
and kindred animals communicated 
to man by direct inoculation; rabies. 

Hypodermic injection. Deposit 
of a solid or fluid beneath the skin 
by means of a syringe and hollow 
needle. 

Hypostasis. The settling of blood 
or fluid to the lowest parts of the body 
by gravitation after death, or loss jof 
pressure-controlling power in a given 
set of blood-vessels. 

Hysterectomy. Removal of the 
womb by operation. 



I. 



Icterus. Bile-stained; jaundiced. 

Immunity. A condition in which 
a body resists the development of 
micro-organisms or the action of their 
poisons. 

Immunizing unit. A standard 
strength agent to subdue the powers 
of a given quantity of micro-organ- 
isms or their products. 

Infectious disease. One capable 
of being transmitted from one person 
to another. 

Infective. Likely to produce dis- 
ease. 

Infective puerperal endometritis. 
Purulent inflammation of the lining 
of the womb after childbirth. 

Inflammation. Reaction of a part 
to an irritant. 

Infusion. Charging the veins with 
fluid by injection. 

Inoculation. The act of directly 
implanting disease. 

Inoculous. Rendered sterile. 

Insomnia. Unable to sleep. 

Inspissated. Dried and thickened 
from loss of water. 

Intestinal adhesion. Union of 
two peritoneal surfaces of the bowel 
caused by inflammatory action. 

Intestines. The bowels. 

Intracerebral injection. Deposit 
within the cavities of the brain. 

Intravenous. Within the veins. 

Intravenous injection. An injec- 
tion forced directly into a vein or 
cellular tissue. 

Intubation. Operation of passing 
a tube through the larynx when closed 
by disease, as in diphtheria. 

Isolation. Setting apart from all 
communication with others. 



GLOSSARY 



323 



Knuckle of intestine. A short 
length of gut sharply bent upon 
itself. 

Kraske's operation. Operation 
devised by the surgeon whose name 
it bears for the removal of cancer 
growing high up in the rectum. The 
diseased area is exposed by chiselling 
away the coccyx and portions of the 
sacrum. 

L. 

Lanolin. A bland, fatty substance 
prepared from sheep's wool and used 
as the base of many ointments. 

Laparotomy sheet. Linen sheet 
covering containing a longitudinal 
opening through which patient's ab- 
domen is exposed. 

Lavage. Washing by irrigation. 

Leprosy. A chronic obscurely 
contagious disease caused by the 
bacillus of leprosy, and giving rise 
to various inflammatory lesions of 
the skin and internal organs. 

Leprous nodules. One form of 
skin lesion caused by leprosy con- 
sisting of firm, irregular elevations, 
which later break down and become 
ulcers. 

Leukocytes. Unit masses of pro- 
toplasm or the physical life principle. 

Ligation. The tying off of blood- 
vessels, the ovarian tubes, the appen- 
dix, or a tumor by means of a gut or 
silk string. 

Liquefied. Changed from a solid 
to a liquid state. 

Lister ism. Antiseptic surgery ac- 
cording to the principles first laid 
down by Sir Joseph Lister. 

Litholapaxy. The operation of 



removal of stone from the bladder 
by crushing and washing out the frag- 
ments. 

Lithotomy. The operation of cut- 
ting for stone. 

Lithotrite. An instrument for 
crushing stones within the bladder. 

Lubricant. A substance used to 
diminish friction; rendering slippery. 

Lymphatic vessels and glands. 
The great system of absorbents with 
their connecting channels. 



M. 

Malady. Sickness, disease. 

M alignant turn or . O ne which has 
undergone cancerous change. 

Masticated. Chewed. 

Meatus. Anatomical name for the 
mouth of a canal. 

Media. The means of transmis- 
sion; substances favorable for the 
growth of bacteria. 

Mediastinum. The middle space 
of the chest cavity between the lungs, 
and containing the heart and great 
blood-vessels. 

Medicaments. Medicines. 

Menstruum. A fluid carrier or 
solvent for a drug. 

Miasm. Infection carried in the 
emanations from the soil. 

Miasmatic. Caused by infectious 
particles rising in vapors from the soil; 
said of malaria before its cause was 
known. 

Micrococci. Germs having a 
spherical shape. 

Micro-organisms. Any form of 
germ life. 

Minim. A fluid drop. 

Monomorphous. Having but one 
form. 



; -- 



GLOSSARY 



N. 

Narcotized. Poisoned by the action 
of a narcotic, as opium. 

Natural rhythm of respiration. 
Normal breathing. 

Nerve -center. One of the count- 
less impulse generators or reflectors 
in the body. 

Neutralization. The act of ren- 
ieiing free or open- 
Nidus. Center of activity. 
Nutrient. Having food value. 

0. 

Occlusion. Closing up. 

Ophthalmic. Relating to (he eye. 

Organic ferment. The microbic 
action which gives rise to souring. 

Organized exudate. A fluid dis- 
charge made solid by the formation 
of fibrin. 

Otitis media. Inflammation of 
the chambers of the middle ear. 

Ova. Eg 

Ovaries. The two egg-bearing 
organs in the female. 

Oxidation. Burning up. 

Oxygenation of the blood. Re- 
g of the blood by the action of 
the red cells in taking up oxygen. 

P. 

Parasitic organisms. Dependent 

upon other forms of life for their 
food; may live in or upon the s 
ing organism. Gonococci are para- 
sites, as are also tapeworms and lice. 
Pasteur chamber and filter. An 
apparatus for sterilizing and filtering 
by the action of superheated steam. 
varied in pressure by means of an air- 
pump. 



Pathogenic bacteria. 
producers. 

Pathologist. One engaged in the 
study of the causes and results of dis- 
ease. 

Pebrin. A hereditary contagious 
disease of silkworms consisting of the 
development of peculiar parasitic cor- 
puscles which invade the eggs, blood, 
and tissues of die worms, causing 
black spots to appear externally. 

Pedicle. An elongated support. 

Pedicle silk. Strong silk used to 
tie off the base of tumors before re- 
moval for security against bleeding. 

Pellicle. Surface scum; an outer 
limiting membrane. 

Pelvic cavity. Space within the 
pelvis. 

Pelvimeter. Curved dividers used 
: bstetrician in calculating the 
size of a woman's pelvis. 

Pelvis. The bony framework at 
the base of the spinal column sup- 
porting the trunk and affording at- 
tachment for the thighs. 

Perforator. A sharp, spear-headed 
instrument used by obstetricians to 
pierce :he skull (to facilitate delivery) 
of a dead infant or one whose life 
must be sacrificed for the good of the 



Perineal lithotomy. The breech 
operation of cutting for stone. 

Perineorrhaphy 

ing up a torn breech of a 
woman. 

Peristalsis. The muscular 
motion of the bowels. 

Peristaltic action. The motion 
which propels the contents of the 
bowels. 

Peritoneal cavity. The space oc- 
cupied by the abdominal organs. 

The lining mem- 



GLOSSARY 



325 



brane of the belly cavity and cover- 
ing of the organs contained. 

Peritonitis. Inflammation of the 
lining membrane of the organs and 
cavity of the abdomen. 

Petri dishes. Small double dishes 
for the cultivation of micro-organ- 
isms. 

Phagocytes. Body cells whose sup- 
posed function is to devour other cells 
as micro-organisms. 

Phagocytosis. The function of 
active destruction by devouring or 
englobing of one cell by another. 

Pharyngeal paralysis. Loss of 
voluntary power of swallowing, with 
dropping of the soft palate. 

Placenta. The late womb con- 
nection between a fetus and its 
mother. 

Plague. An acute contagious dis- 
ease commonly appearing in epidemic 
form due to micro-organisms char- 
acterized by bubo formation and high 
death-rate. 

Plasma. The fluid portion x>f 
blood or lymph. 

Pleurisy. Inflammation of the 
pleura or membranous covering of the 
lungs and lining of the chest walls. 

Pneumonia. Inflammation of the 
lungs. 

Precipitated. Thrown down by 
chemical action. 

Preparatory treatment. Mak- 
ing a patient ready for an operation, 
consists in local cleansing, attention 
to bowels and bladder, food, etc. 

Prone. Lying upon the abdomen. 

Prophylaxis. Preventive meas- 
ures. 

Protective dressing. A water- 
proof material placed next to a 
wound according to the direction of 
Sir Joseph Lister. 



Puerperal. Relating to child- 
birth. 

Puerperal fever. Elevation of 
body temperature occurring in infec- 
tion after childbirth. 

Puerperal infection. Systemic 
poisoning by the action of micro- 
organisms in a child-bearing woman. 

Pure culture. Containing but one 
variety of germs. 

Purgative. A substance which 
moves the bowels. 

Pus. Matter given off from an 
open sore. 

Putrefaction. Separation of an 
organic compound into the elements 
of which it is composed by the action 
of micro-organisms; rotting. 

Pyroxylin. Gun-cotton; made by 
immersing raw cotton in nitric and 
sulphuric acids. 



Raw surface. An open wound or 
abrasion; a condition in which the skin 
or outer lining of a part or organ is 
broken through. 

Reaction. The restoration of vital- 
ity after shock. 

Rectum. The lower extremity of 
the large intestine. 

Recurrent. Returning again. 

Regurgitation. A back flow. 

Respiration. Breathing. 

Retention of urine. That condi- 
tion in which the urine, while it con- 
tinues to be formed by the kidneys, 
cannot be passed from the body; in- 
ability to pass water. 

Revulsion. A rejection; counter- 
irritation. 

Rigor. Sense of coldness accom- 
panied by a superficial convulsive 
seizure. 



326 



GLOSSARY 



S. 



Salicylated. Containing a given 
amount of salicylic acid. 

Saliva. Spittle. 

Saprophytic organisms. Those 
living in or on decaying organic mat- 
ter. 

Sarcoma. A form of cancer of 
rapid growth and occurring most 
often in the young. 

Saturated. Fully filled; soaked. 

Scapula. The shoulder-blade. 

Scarify. To cut into. 

Scarlet fever. An acute conta- 
gious disease of childhood giving rise 
to high fever, rapid pulse, a rose-red 
rash, and with a marked tendency to 
be followed by kidney disease. 

Scultetus bandage. An over- 
lapping many-tailed bandage dress- 
ing. 

Secretions. Special substances 
thrown off by functionally active 
organs. 

Sedative. Soothing; softening. 

Septic. Relating to putrefaction 
or pus-germ infection. 

Septic discharge. Purulent; con- 
taining pus germs. 

Septic peritonitis. Inflammation 
of the lining membrane of the organs 
and cavity of the abdomen caused by 
the action of pus germs. 

Septicemia. A severe form of 
blood poisoning in which both germs 
and their products are current in the 
blood. 

Sequelae. After-effects of dis- 
ease. 

Sequestrum. A dead mass, as a 
fragment of a dead bone. 

Serum. The watery part of drawn 
blood separating on standing; the fluid 
in a blister. 



Shock. The constitutional effect 
of a disease or injury. 

Sinus. A disease tract or channel 
left after the discharge of a purulent 
collection. 

Specific bacteria. Germs directly 
responsible for the given disease. 

Sphincter muscle. Anatomical 
name for muscles whose actions are 
to close openings, as at the mouth 
and anus. 

Spica. A spiral bandage done 
with a roller in a series of figure 
eights. Most used for the shoulder, 
groin, thumb, and great toe. 

Spirilla. Spiral-shaped germs, as 
the spirillum of cholera (also called 
the comma bacillus). 

Splenic fever. Disease due to the 
anthrax bacillus; wool-sorter's dis- 
ease. 

Spore. A germ seed. 

Spotted fever. Epidemic cerebro- 
spinal meningitis or cerebrospinal 
fever; a specific infectious disease of 
the membranes of the brain and spinal 
cord and accompanied by a peculiar 
dusky rash. 

Sterilization. Act of rendering 
free from germs. 

Sterilize. To kill all germ life. 

Stethoscope. An instrument for 
listening to the flow of air or blood 
inside the body. 

Stimulation. Arousing to greater 
action; urging. 

Subcutaneous injection. One 
made beneath the skin. 

Subnormal temperature. Degree 
of body heat below 9S F. 

Supine. Outstretched upon the 
back. 

Suppression of urine. A condi- 
tion in which the kidneys cease to 
act, no urine being formed. 



GLOSSARY 



327 



Suppuration. The last stage of 
inflammation," manifested by destruc- 
tion of tissue with pus formation. 

Suprapubic lithotomy. Cutting 
operation for stone in the bladder 
attacked from above. 

Surgically clean. As nearly as is 
possible to be free from germ life. 

Sutures. The material with which 
a surgeon sews; the stitches them- 
selves. 

Syncope. Sudden loss of power 
and consciousness; fainting. 

T. 

Tampon. A gauze or cotton plug; 
may have a string or tape attached 
for withdrawal. 

Technic. The mode of working; 
plan or method of work. 

Tepid. Moderately warm. 

Tetanus. Lockjaw; a very dan- 
gerous germ disease characterized by 
locking of sets of muscles due to the 
presence of a poison developed by 
tetanus bacilli. 

Therapeutics. The science of the 
application of medicines for the cure 
of diseases. 

Thoracic cavity. The chest. 

Toxicity. Degree of poison. 

Toxin. Poison formed by germ 
life. 

Trachelorrhaphy. Operation for 
the repair of a torn mouth of the 
womb. 

Tracheotomy. Operation of cut- 
ting open the windpipe below the 
larynx for the purpose of admitting 
air to the fungs; done for closure of the 
upper air-passages. 

Traumatic delirium. Brain ex- 
citement following serious body in- 
jury. 



Trikresol. A refined mixture 
made from carbolic acid. 

Tubercles. Local effects of the 
action of tubercle bacilli consisting 
of cheesy masses. 

Tuberculosis. An infectious dis- 
ease giving rise to general or local 
disorganization caused by the tuber- 
cle bacillus; consumption. 

Tumefaction. A swelling. 

Turpentine stupe. A piece of 
cloth or flannel dipped in spirits of 
turpentine after wringing out in hot 
water. 

Tympanites. Distention of the 
abdomen caused by excess of gas in 
the stomach and bowels; may become 
drum-like. 



Ulcer. A sore, attended by dis- 
charge. 

Ulceration. Superficial death of 
a part. 

Ulcerative endocarditis. A severe 
inflammation of the heart, ending 
with destruction of the valve leaflets. 

Undertaker's stretcher. A port- 
able board and trestle inclined table 
upon which a corpse is laid during 
the process of embalming. 

Uremic coma. Loss of conscious- 
ness and physical condition following 
the absorption of urinary poisons 
in the late stages of kidney dis- 
ease. 

Ureter. The tube leading from 
the kidney to the bladder. It is of 
the diameter of a goose quill and 
about sixteen inches in length. 

Urethra. The water pipe from 
the bladder. 

Urethral calibrator. An instru- 
ment for determining the size of the 
canal. 



328 



GLOSSARY 



Urination. The act of passing 
water. 

Uterine appendages. The ovaries, 
Fallopian tubes, broad and other at- 
taching ligaments of the womb. 

Uterus. The womb; the hollow, 
pear-shaped pelvic organ which is 
destined to retain the child from the 
moment of its conception until the 
time of its expulsion at birth. 



V. 

Vaccination. Inoculation of cow- 
pox lymph into the arm as a protec- 
tion from small-pox. 

Vacuum. Space in which there is 
no air. 

Vagina. The female genital canal. 

Vaginal discharge. A flow from 
the genital canal. 

Vaginal hysterectomy. Removal 
of the womb through the lower gen- 
ital canal. 

Vascular. Pertaining to vessels. 



Venesection. Bleeding; opening 
a vein to let out blood. 

Venom. Animal poison. 

Venous pressure. The weight 
and flow power of the blood stream 
in the veins. 

Venules. Smallest branching veins. 

Vertex. The crown of the head; 
highest point of the skull. 

Vestibule. The beginning of the 
female genital canal. 

Virulence. Poison-strength. 

Virulent. Highly poisonous; de- 
structive. 

Virus. Any form of organic poison. 

Viscera. The contents of the large 
cavities of the body. 

Viscosity. Stickiness. 

Vulva. The external genitals, pri- 
vate parts, the female external organs 
of generation. 

w. 

Wound drainage. A method of 
providing for the escape of pus or 
serum drip from a wound. 



INDEX 



Abdomen, infections of, after op- 
eration, 257 
Abdominal cavity, apparatus for 
douching of, 226 
operations, instruments for, 131 
Abscess, incision of, for drainage, 

227 
Absorbent cotton, 180 
Accidents during operation, 275 
Acclimatization, immunity, 39 
Acids, mineral poisoning by, 230 
Aconite poisoning, 230 
Actinomycosis, communication of, 

to man, 22 
Adhesive plaster, 93 

figure-of-8 of knee, 95 
moleskin, 93 
pelvic binder, 95 
resin, 93 
rubber, 93 

strapping of ankle-joint, 96 
of chest, 94 
of joints, 95 
of leg ulcers, 95 
zinc oxid, 93 
Aerobic bacteria, 34 
Age, effect of, on bacteria, 34 
Air, effect of, on bacteria, 34 
Akoin anesthesia, 171 
Albumin water, 299 
Alcohol as germicide, 60 

rubs after fracture, 101 
Alimentary canal, entrance of bac- 
teria in, 35 
Allis' ether inhaler, 152 
Alypin anesthesia, 171 
Amphitheater, clinical, 243 
Amputating knives, 132 
Anaerobic bacteria, 34 
Anesthesia, 144 

care of bowels before, 144 
of patient in, 147 



Anesthesia, chloroform, 155 

conduction, 169 

delayed poisoning in, 167 

diet before, 145 

drugs before, 145 

endoneural, 169 

ether, 150. See also Ether. 

ethyl chlorid, 158 

first stage, 149 

infiltration, 169 

intrapharyngeal inhalation, 160 

intratracheal insufflation, 161 

local, 168 
cocain, 168 

cracked ice and salt, 168 
ethyl chlorid, 168 

method of holding jaw in, 154 

nitrous oxid, 156 
ether, 158 

oil-ether colonic, 166 

perineural, 169 

physical examination before, 146 

precautions in, 144 

preparation for, 144 

of mouth and teeth for, 145 

rectal, 166 

scopolamin-morphin, 166 

second stage, 149 

special methods of, 160 

spinal, 172. See also Spinal 
anesthesia. 

stages of, 148 

third stage, 149 

vapor apparatus for, 151 
Anesthetic paralyses, postoperative, 

167 
Anesthetics, varieties of, 144 
Anesthetist's supplies, 147, 148 
Aneurysm needle, Deschamp's, 136 
Ankle-joint, adhesive plaster strap- 
ping of, 96 
Anoci-associatidn, 264 

329 



330 



INDEX 



Anthrax bacillus, discovery of, 20 
discovery of bacterial nature of, 
.23 

Antidotes, 230-232 
for carbolic acid, 59 
for corrosive sublimate, 57 

Antimony tartrate poisoning, 230 

Antisepsis, origin of, 22 

Antiseptics, 53 
abuses of, 63 

Antiseptic solutions, 64 
surgery, 20 

Antistreptococcic serum in perito- 
nitis, 273 
therapeutic value of, 50 

Antitoxic theory of immunity, 41 

Antitoxin, cerebrospinal meningi- 
tis, 50 
diphtheria, dose of, 49 
process of making, 46 
status of, 49 
method of injecting, 51 
reactions from, 51 
streptococcus, preparation of, 47 
tetanus, 50 

therapeutic action of, 47 
tuberculosis, preparation of, 47 

Antitoxins, 45 
theory of, 45 

Antituberculosis serum, 51 

Antityphoid vaccine, 50 

Apple water, 299 

Argyrol as disinfectant, 61 
as germicide, 61 

Aristol as germicide, 63 

Arrowroot gruel, 301 

Arsenic poisoning, 230 

Artificial respiration, 267 
in surgical shock, 266 

Asepsis in gynecologic examina- 
tions, 289 

Aspirator, Potain's, 137 

Assistant nurses, duties of, at 
operation, 256 

Atropin poisoning, 230 

Autopsies, 306, 308 
cleanliness in, 310 
instruments, etc., for, 309 
preparation of body for, 309 
time for, 308 

Auvard's self-retaining speculum, 
138 



Babcock's solution for spinal anes- 
thesia, 177 
Bacilli, 29 
Bacillus aerogenes capsulatus, 43 

anthrax, discovery of, 20 

coli communis, 42 

comma, discovery of, 25 

melitensis, 27 

of bubonic plague, discovery of, 
26 

of diphtheria, 44 
discovery of , 25 

of glanders, discovery of, 25 

of influenza, discovery of, 26 

of membranous croup, 44 

of pneumonia, discovery of, 25 

of tetanus, 43 

of tuberculosis, 25, 43 

pyocyaneus, 43 

typhoid, discovery of, 24 
Back, figure-of-8 bandage of, 76 
Bacteria, 29 

aerobic, 34 

agents capable of destroying, 54 

anaerobic, 34 

as causes of disease, 28 

conditions influencing growth of, 

33 
definition of, 28 
distribution of, 17 
effect of age on, 34 

of air on, 34 

of drying on, 34 

of sunlight on, 33 
entrance of, into alimentary 
canal, 35 

into respiratory tract, 35 
forms of, 28, 29 
incubation period of, 38 
mode of entrance of, 34 
pathogenic, 29 
reproduction of, 32 

by binary division, 32 

by fission, 32 

by sporulation, 32 
sizes of, 28 
soil required for, 34 
Bacteriology, 17 
history of, 17 
progress in, 18 
Baking treatment, 227 
Balsam of Peru, 194 



INDEX 



331 



Bandage, application of, 66 
Barton's, 68 

Christy knife for cutting, 67 
demigauntlet dorsal, 84 

palmar, 85 
double crossed, of both eyes, 74 
figure-of-8, of back and chest, 
76 

of head and neck, 74 
Gibson's, 69 
Liebreich's eye, 72 
machine for, 65, 66 
materials for, 65 
mitre box for cutting, 67 
occipitofrontal, 71 
of breast, compressor, 74 

double, 75 

suspensory, 74 
of eye, crossed, 72 
of finger, spiral, 83 

reverse, 84 
of groin, descending spica, 86 

double spica, 87 

single spica, ascending, 85 
of leg, figure-of-8, 88 
of lower leg, spiral reverse, 80 
of knee, figure-of-8, 87 
of stump, recurrent, 87 
of thumb, spica, 84 
plaster-of-Paris, 98 

application of, 98 

removal of, 99 
recurrent, 70 

double head, 71 
removal of, 68 
rolling by hand, 65 
scultetus, 92 

shoulder, descending spica of, 79 
spica, of shoulder, 77 
to overlap, 67 
to recur, 67 
to reverse, 67 
to secure, 68 
Velpeau's, 78 
Bandaging, 65 
Barley gruel, 301 

water, 299 
Barton's bandage, 68 
Basin, pus, 112 
Bath thermometer, 208 
Beck's bismuth paste, 194 
Bed arranged for childbirth, 234 



Bed, ether, 284 

Gatch, 186 
Bed-pan sterilizer, in 
Beef broth, 304 

essence, 304 

juice, 305 
Belladonna poisoning, 230 
Bellocq's cannula, 271 
Bichlorid of mercury as germicide, 

.5 6 
Bier's hyperemia, 223 

Bigelow's evacuator, 142 

Bismuth paste, Beck's, 194 

Bladder, care of, after operation, 

258 

irrigation of, 202 
Blastomycetes, 29 
Boiling water, sterilization with, 55 
Bone gouge, 141 
Bone-cutting forceps, 141 

instruments, Macewen's, 141 
Bone-plating, instruments for, 139 
Boric acid as germicide, 63 
Bowels, care of, after operation, 258 
Breast bandage, compressor, 74 
double, 75 
suspensory, 74 
Breast-binder, Murphy, 236 
Broth, beef, 304 

chicken, 305 

mutton, 305 
Brushes, 184 
Bubonic plague bacillus, discovery 

of, 26 
Buck's extension, 97 

mastoid curet, 126 
Button suture, 216 



Cabinet for instruments, 102 
Cannula, Bellocq's, 271 

Luer's trachea, 127 
Cantharides poisoning, 231 
Carbolic acid, 52 
as germicide, 58 
poisoning, 59, 230 
Cargile membrane, 188 
Carotid arteries, instruments for 

ligation of, 129 
Catgut, 190 

chromicized, 192 

iodin, 191 



35? 



INDEX 



Catgut, sterilization of, 190 
Catheter. Gouley s tunneled, 142 

introduction of, 201 

straps :- ; 
Catheterization, 200 

: ys litis from, 200 
Catheters, glass. 200 

sterilization of. 200 
Catling's amputating knives, 132 
Cautery. Paquelin. : : 
Cerebrospinal meningitis, antitoxin 
in. 50 
cause of. 26 
Cervix, instruments for dilation of, 

135 

for repair of, 135 
Chart, medical, 121 
keeping of, 116 
Chest, ngure-of-S bandage of, 76 
instruments for operations on, 131 
strapping of, with adhesive plas- 
ter. 04 
Chicken-broth. 305 
Childbirth, bed arranged for. 234 
Chlorid of lime as disinfectant, 61 
Chlorin- water poisoning, 231 
Chloroform anesthesia. 155 

poisoning. 231 
Christy knife for cutting bandages, 

6 ' 
Chromicized catgut, 192 

Cigarette-drain. : : - 

Cinnamon and milk. 301 

Circulation, absence of, as sign of 

death ,307 
Circumcision, instruments for, 143 
Clamps. Michel's. 194 
Clinical thermometer. ; ; 8 
Clothing for infant. 236 

hospital, for patient. : 5 : 
Coaptation splints. 100 
Cocain local anesthesia. 168 

poisoning, treatment of. 170 
Cocci, 29. 30 

morphology of. 30 

pus-formic s 

pyogeni 
Colchicum poisoning 
Cold, therapeutic use of. 218 
Coley's serum for malignant tumors, 

---- 
reaction from. 51 



Collins' retractor, 137 
Collodion. 227 

dressing, 183 
Colon tube with funnel. : : 3 
Comma bacillus, discover}* of, : 5 
Compresses, 101 

Compressor bandage of brea;: - 4 
Conduction anesthesia, 169 
Conium poisoning. : 
Continuous suture, 216 
Copper sulphate poisoning. 231 
Cornstarch, 304 

Corrosive sublimate as germicide, 
56 
poisoning, 231 
tablets, 57 
Cotton, 227 

absorbent, 181 

glives. :SS 

— 2.5: e. :>: 
Cotton-gauze dressings, 180 
Counterirritation, 216 
Cracked ice and salt for local anes- 
thesia, 168 
Cracker gruel, 302 
Creolin as germicide, 60 
Crile's anoci-association. 264 
Croton oil poisoning. 231 
Cupping, 218 

instruments for. : : □ 
Curet, Buck's mastoid, 126 

DeRoalde's adenoid, 128 

Sims' sharp. 138 

Thomas' dull, 138 
Curetment of uterus, instruments 

for, 135 
Currant juice. 300 
Cystitis from catheterization. 200 
"yst -ropy, instruments for. 143 



Death, signs of. 306 

absence of circulatio: 
of heart-beat. 307 
of respiration. 307 
hypostasis. 307 
insertion of needle. 307 
rigor mortis. 307 

rutaneous injection of am- 
monia, 307 
temperature. 308 
Delirium, traumatic, 266 



INDEX 



333 



Deodorants, 53 

DeRoalde's adenoid curet, 128 
Deschamp's aneurysm needle, 136 
Desmarre's lid retractor, 130 
Dewitt's appliance for rectal irriga- 
tion, 210 
Diet after childbirth, 235 

after gynecologic operations, 298 

before anesthesia, 145 

milk, 300 

recipes, 299 
Diet-list after operation, 260-262 
Digitalis poisoning, 231 
Dilator, Goodell-Lentz uterine, 140 

Sinexon's nasal, 127 

uterine, 140 
Diphtheria antitoxin, dose of, 49 
process of making, 46 
status of, 49 

bacillus of, 44 
discovery of, 25 
Diplococci, 30 

Diplococcus intracellularis meningi- 
tidis, 26 

pneumonia?, 43 
Disease, bacteria as causes of, 28 

in man, fungi connected with, 29 
Dish, Petri, 247 
Disinfectants, 53 
Disinfection, 54 

by steam, 55 
Dorsal position, 291 
Douche, vaginal, 207 
antiseptic, 208 
apparatus for, 209 
Draeger pulmotor, 269 
Drainage, incision of abscess for, 
227 

of wounds, 185 

postural, 186 
Drainage-tubes, 185, 188 

care of, 187 

rubber, preparation of, 187 
Dressings, 180 

collodion, 183 

cotton-gauze, 180 

forceps for, 133 

gauze for, 180 

Sayre's, 93 

table, 255 

tray, instruments for, 122 
Dressing-room ledger, 114 



Dressing-room outfit, 184 

Drop method of ether anesthesia, 

i53 
Dry cups, 219 
Drugs before anesthesia, 145 

Ear operations, instruments for, 
125 

Ecgonin, 169 

Edebohls' dorsal posture, 292 

Effervescing lemonade, 300 

Egg lemonade, 300 

Eggs, 302 
poached, 302 
scrambled, 303 
shirred, 303 

Elaterium poisoning, 231 

Electricity, 228 

Elevator, Langenbeck's periosteal, 
126 

Emergency bundles, 184 
operations, 286 

Emmett's angular bent scissors, 133 

Endoneural anesthesia, 169 

Enema for tympanites, 214 
stimulating, 213 

Enemata, purgative, 214 

Enteroclysis, 209 

Ermold's tonsillotome, 128 

Esmarch's tourniquet, 270 

Essence, beef, 304 

Ether anesthesia, 150 

cases suitable for, 150 
closed inhaler for, 151 
drop method of, 153 
Gwathmey apparatus for, 152 
open method, 150 
semi-open method, 151 
vapor method of, 152 
bed, 284 
inhaler, Allis', 152 

Ethyl chlorid anesthesia, 158 
local, 168 
tube, 158 

Eucain anesthesia, 171 

Evacuator, Bigelow's, 142 

Examinations, gynecologic, 289, 
290. See also Gynecologic ex- 
aminations. 

Extremities, instruments for opera- 
tions on, 135 

Eye, bandage of, crossed, 72 



334 



INDEX 



Eye, bandage of, Liebreich's, 72 
double-crossed bandage of, 74 
instruments for operations on, 
129 



Fecal fistula, 275 
Feeding of infant, 236 

artificial, 237 
Feet, care of nurses', 312 
Fermentation fever after operation, 

273 
Finger cots, 189 

spiral bandage of, 83 
reverse bandage of, 84 
Fire, destruction of germs with, 54 
Fish, poisoning by, 232 
Fission, 32, 33 
Fistula, fecal, 275 

urinary, 275 
Flacherie, 24 
Flaxseed tea, 301 
Flesh, proud, 199 
Flexner's serum for infantile palsy, 

5i 
Flour ball, 302 
Foot-bath, mustard, 217 
Forceps, bone-cutting, 141 

dressing, 133 

Hudson's cranial rongeur, 123 

iris, 130 

Linnartz's stomach clamp, 136 

placental, 140 

Richards' tonsil -hoi ding, 128 

Segond's volsella, 134 

Stone's tissue, 133 

Tait's hemostat, 134 
Formaldehyd as disinfectant, 61 

generator, 62 
Fountain syringe, 285 
Fowler position, 186 
Fox's eye speculum, 130 
Fracture, alcohol rubs after, 101 

care of soft parts after, 101 
Fracture-box, 100 
Fungi connected with disease in 

man, 29 



Gall-bladder, instruments 

operations on, 131 
Gant's pile clamp, 143 



for 



Gastric lavage, 207 

Gatch bed, 186 

Gauze for dressings, 180 

iodoform, 181 

medicated, 180 

packing, 183 

pads, 179 

sponges, 178 

sublimate, 180 
Generator, formaldehyd, 62 
Genupectoral position, 292 
Germ theory of disease, 20 
Germicides, 52 

abuses of, 63 

chemical, 56 
Gibson's bandage, 69 
Gigli wire saw, 123 
Glanders bacillus, discovery of, 25 
Glands of neck, instruments for re- 
moval of, 129 
Glass trays, 112 
Glovers' suture, 216 
Gloves, 188 

Goodell-Lentz uterine dilator, 140 
Goiter, instruments for operation 

on, 129 
Gouge, bone, 141 
Gouley's tunneled catheter, 142 
Gowns, 184 

operating, 244 
Gram's method of staining, strep- 
tococcus, 31 

solution, 31 
Green soup, 196 

Griffith's anesthetizing stethoscope, 
148 

combined inhaler, 158 

wire-frame chloroform inhaler, 

155 
Groin, descending spica of, 86 
double spica of, 87 
single spica of, ascending, 85 
Gruel, arrowroot, 301 
barley, 301 
cracker, 302 
Guard, Stacke's, for facial nerve, 

126 
Gwathmey apparatus for ether 

anesthesia, 152 
Gynecologic examinations, 289, 290 
asepsis in, 289 
positions in, 290 



INDEX 



335 



Gynecologic examinations, posi- 
tions in, dorsal, 291 

Edebohls' dorsal, 292 

genupectoral, 292 

knee-chest, 292 

latero-abdominal, 291 

lithotomy, 292 

Sims', 291 

upright, 290 

Walcher, 293 
preparation for, 295 
operations, 289 
after-care, 297 
asepsis in, 289 
diet after, 299 



Hands, preparation of, 242 

Harrington's solution as germicide, 
60 
formula for, 61 

Hartmann's round tonsil punch, 
126 

Head, figure-of-8 bandage of, 74 
nurse, duties of, at operation, 253 
operations, instruments for, 122 
operations on, 276 

Heat, effect of, on spores, 33 
sterilization by, 55 
therapeutic use of, 218 

Hemorrhage after operation, 269 
symptoms of, 270 
treatment of, 270 

Hemorrhoids, instruments for op- 
erations on, 143 

Hemostat forceps, Tait's, 134 

Hernia, postoperative, 274 

Herniotomy, instruments for, 131 

High-tension steam, sterilization 
with, 55 

History of patient, taking, 116 

Hoffman's uterine irrigator, 138 

Horsehair, 193 

Horsley's wax, 196 

Hospital clothing for patient, 249 

Hot air, disinfection with, 55 
treatment, 227 

Hudson's cranial rongeur forceps, 
123 
trephine, 124 

Hydrocyanic acid poisoning, 230 

Hydrogen dioxid as disinfectant, 61 



Hydrophobia, Pasteur treatment 

for, 25 
Hygiene for nurses, 311 
Hyperemia, active, 198 

Bier's, 223 
Hyphomycetes, 29 
Hypodermic injection, 215 

method of, 215 
Hypodermoclysis, 222 

apparatus for, 225 
Hyoscyamus poisoning, 231 
Hypostasis, 307 
Hysterectomy, vaginal, 275 



Ice-bag, 198 

Ichthyol, 194 

Illuminating gas poisoning, 231 

Immunity, 38 

acclimatization, 39 

acquired, 39 

artificial, 40 

natural, 39 

phagocytosis theory of, 40, 41 

racial, 39 
Imperial drink, 300 
Incision, deep, 227 

of abscess for drainage, 227 
Infant, care of, 235 

clothing for, 236 

feeding of, 236 
artificial, 237 

nursing of, 236 
Infiltration anesthesia, 169 
Inflammation, causes of, 199 

definition of, 197 

function of, 198 

phenomena of, 197 
Influenza bacillus, discovery of, 26 
Infusion, intravenous, 221 

saline, 224 
Inhalation anesthesia, intrapharyn- 

geal, 160 
Inhaler, chloroform, Griffith's, 155 
Injection, hypodermic, 215 

rectal, 209 
Insanity, postoperative, 275 
Instruments, cabinet for, 102 

care of, 102 

for dressing tray, 122 

for operations, abdominal, 131 
bone-plating, 139 



336 



INDEX 



Instruments for operations, cir- 
cumcision, 143 
curetment of uterus, 135 
cystoscopy, 143 
dilation of cervix, 135 
glands of neck, removal of, 129 
laminectomy, 124 
ligation of carotid arteries, 129 
on chest, 131 
on ear, 125 
on extremities, 135 
on eyes, 129 
on gall-bladder, 131 
on goiter, 129 
on head, 122 
on hemorrhoids, 143 
on hernia, 131 
on intestines, 131 
on kidney, 135 
on liver, 131 

on male genital organs, 139 
on nose, 125 
on stomach, 131 
on throat, 125 
on uterus, 135 
osteoplastic grafting, 139 
perineorrhaphy, 135 
removal of tongue, 129 
repair of cervix, 135 
resection of rectum, 143 
submucous resection, 128 
list of, 122 

required for operations, 116 
roll, 119 

sterilization of, 106 
trays for, no 
Insufflation anesthesia, intratra- 
cheal, 161 
apparatus for, 162-164 
technic of, 165 
Interrupted suture, 216 
Intestinal obstruction after opera- 
tion, 274 
operations, instruments for, 131 
Intradermic injection, 215 
Intravenous infusion, 221 
Iodin catgut, 191 
poisoning, 232 
tincture of, as germicide, 57 
Iodoform as germicide, 62 
gauze, 181 
poisoning from, 62 



Iris forceps, 130 

knife, 130 

scissors, 130 

spatula, 130 
Irrigation of bladder, 202 

of wounds, apparatus for, 225 

rectal, 209 
Irrigator, 253 

Hoffman's uterine, 139 
Invalid's soup, 304 



Jackson's laryngoscope, 165 
Jelly, tapioca, 302 
Joints, adhesive plaster strapping 
of, 95 



Kangaroo tendon, 192 

Kelly's curved round needles, 134 

retractor, 137 
Kidney, instruments for operation 

on, 135 
Kirchner's theory of disease, 18 
Kit, surgeon's, 116 

contents of, 118 

packing of, 118 
Knee bandage, ngure-of-8, 87, 95 
Knee-chest position, 292 
Knife, iris, 130 
Koch's circuit to prove specific 

pathogenic powers of microbe, 

.3° 
discovery of tubercle bacillus, 25 

tuberculin, 26 

Koumiss, 300 



Labarraque's solution, 64 

Labor, diet after, 235 
nurses' duties after, 233 
before, 233 

Laborde's method of artificial res- 
piration, 269 

Laminectomy, instruments for, 124 

Lange's theory of disease, 18 

Langenbeck's periosteal elevator, 
126 

Laryngoscope, Jackson's, 165 

Latero-abdominal position, 291 

Lavage, gastric, 207 

Lead salts, poisoning by, 232 



fNDEX 



337 



Ledger, dressing-room, 114 
operating-room, n 2-1 15 

Leeching, 220 

Leg, bandage of, figure-of-8, 88 
lower, spiral reverse of, 88 
ulcers, adhesive plaster strapping 

of, 95 
Lemonade, 300 

effervescing, 300 

egg, 300 
Lentz's cranial chain tourniquet, 

123 - 

Leprosy, discovery of bacterial 

origin of, 24 
Liebreich's eye bandage, 72 
Ligatures, 190 
Lime-water, 299 
Liniments, 219 
Linnartz's stomach clamp forceps, 

Lister's antiseptic surgery, 20 
Liston's amputating knives, 132 
Lithotomy position, 283, 292 
Lithotrite, 142 
Liver, instruments for operations 

on, 131 
Live steam, sterilization with, 55 
Lobelia poisoning, 232 
Local anesthesia, 168 

alypin, 171 

akoin, 171 

eucain, 171 

novocain, 170 

phenol, 171 

Schleich's solutions for, 170 

tropacocain, 171 

with cracked ice and salt, 168 
Lombard nasal tube for ether anes- 
thesia, 151 
Luer's hypodermic syringe, 146 

trachea cannula, 127 
Lysol as germicide, 60 



Macewen's bone-cutting instru- 
ments, 141 

Malaria, cause of, 27 

Male genital organs, instruments 
for operations on, 139 

Malta fever, cause of, 26 

Marine sponges, 179 

Massage, 227 
22 



Mayo's operating scissors, 133 
scalpel, 132 

Mayo-Simpson's self-retaining re- 
tractor, 136 

Medical chart, 121 

Medicated gauze, 180 

Membrane, cargile, 188 

Membranous croup, bacillus of, 44 

Meningitis, cerebrospinal, cause of, 
26 

Mercury bichlorid as germicide, 56 
poisoning from, 57 

Metchnikoff's theory of phagocyto- 
sis, 41 

Metric system, 64 

Michel's clamps, 194 

Micrococcus lanceolatus, 43 

Milk and cinnamon, 301 
diet, 300 

mixtures, 237, 238 
toast, 303 

Mineral acids, poisoning by, 230 

Miter box for cutting bandages, 
67 

Molds, 29 

Moleskin adhesive plaster, 93 

Montgomery straps, 98 

Morphin poisoning, 232 

Mosetig-Moorhof wax, 195 

Mosquito transmission of malaria, 
27 
of yellow fever, 26 

Murphy breast-binder, 236 
button, 136 

drop method of rectal irrigation, 
210 

Mustard foot-bath, 217 
plaster, 217 

Mutton-broth, 305 



Neck, figure-of-8 bandage of, 74 

operations on, 277 
Needles, 122 

insertion of, as sign of death, 307 
Kelly's curved round, 134 
Needle-holder, Noble's improved 

Reiner's, 134 
Nitrous oxid anesthesia, 156 
administration of, 157 
apparatus for, 156 
ether anesthesia, 158 



INDEX 



Noble's improved Reiner's needle- 
holder, 134 

Nose, instruments for operations 
on. 125 

Novocain anesthesia. 170 

Nozzle, vagina] douche. 209 

Nurses' conduct in sick-room, 314 
feet, care of. 312 
hygiene for. 311 
life, personal conduct of. 311 
periods for relaxation. 314 
personal appearance. 314 

conduct of. 310 
preparation of. for operation. 241 
rewards, success of. 278 

Nursing of infant, 235 
obstetric, 233 

Nux vomica, poisoning from, 232 



Obstetric nursing. 233 
Occipitofrontal bandage. 71 
Oil-ether colonic anesthesia, 166 
Ointments. 219 
Operating gown. 244 
Operating-room. 245 

care of, 102 

duties of nurse in. 241 

equipment of. 105 

ledger, n 2-1 15 

preparation of. 239. 240 

spectator's dress for. 246 
Operating-table. 274 
Operations. 239 

accidents during. 275 

arranging patient for, 253 

blank. 120 

care of bladder and bowels after, 
258 
patient after. 256 

diet-list after. 260-262 

dress for. 242 

duties of assistant nurses at. 256 
of head nurse at. 255 

emergency, preparations for, 286 

fermentation fever after. : - ; 

gynecologic, 280. See also Gyne- 
cologic operations. 

hemorrhage after, 269. See also 
Hi worrhazc after operations. 

infections of abdomen after. 257 

in private practice. 278 



Operations in private practice, 
articles required for. 2S4. 

. 2 . 8 s 

giving anesthetic in, 286 
operating-table for. 281, 282 
preparations for, 280 
instruments for 116. 122-143. 
See also Instruments for opera- 
tions. 
intestinal obstruction after, 274 
of election, 240 
of emergency. 240 
of expediency, 239 
of necessity. 239 
on head, 276 
on neck. : -- 
peritonitis after. 272 
preparation of field of, 251 
patient for. 250 
day before, 250 
on day of, 2^2 
sequelae of. 263 
shock after. 263 
sinus after. 275 
special. 276 
tympanites after. 273 
varieties of. 239 
visitors after. 260 
Opium poisoning. 232 
Orangeade, 300 
Osteoplastic grafting, instruments 

for. 139 
Oxalic acid as germicide. 63 
poisoning, 232 



Packing, gauze. 183 

Pads, gauze. 179 

Pagenstecher sutures. 193 

Palmer bandage, demigauntlet. 84 

Panado. 303 

Paquelin cauterv, 220 

Paralysis, infantile. Flexner's serum 

in. 51 
Paralvses. postoperative anesthetic. 

167' 
Paste. Lnna's. 105 
Pasteur's germ theory of disease. 20 

treatment of hydrophobia. 25 
Patient, arranging of. for operation, 

253 
care of, after operation, 256 



INDEX 



339 



Patient, hospital clothing for, 250 
preparation of, for operation, 250 
day before, 250 
on day of, 252 
taking history of , 116 
transportation of, 249 
Pathogenic bacteria, 29 
Pelvic binder, adhesive plaster, 95 
Perineorrhaphy, instruments for, 

135 
Perineural anesthesia, 169 
Peritonitis after operation, 272 
antistreptococcic serum for, 

273 
treatment of, 272 
Personal conduct of nurse's life, 311 
Petri dish, 247 
Phagocytes, 40 
Phagocytosis, 40 
Phenol anesthesia, 171 
Phosphorus poisoning, 232 
Pile-clamp, Gant's, 143 
Pebrine, 24 

Plasmodium malariae, 27 
Plaster, 227 

adhesive, 93 
Plaster-of-Paris bandage, 98 

application of, 98 

removal of, 98 

splints, 100 
Pneumococcus, 43 

discovery of, 25 
Pneumonia, bacillus of, 43 

mode of infection in, 35 
Poached eggs, 302 
Poisoning from carbolic acid, 59 

cocain, treatment of, 170 

from corrosive sublimate, 57 

from iodoform, 62 

from mercury bichlorid, 57 
Poisons and antidotes, 230-232 
Postoperative hernia, 274 

insanity, 275 
Postural drainage, 186 
Potain's aspirator, 137 
Potash poisoning, 232 
Potassium permanganate as germi- 
cide, 59 
Private practice, operations in, 278 
Proctoclysis, continuous, apparatus 
for, 211 
method of, 212 



Proud flesh, 199 

Pudding, tapioca, 304 

Puerperal fever, Semmelweis' the- 
ory of, 23 

Pulmotor, Draeger, 269 

Punch, Hartmann's round tonsil, 
126 

Puncturation, 226 

Puncture, deep, 227 

Purgative enemata, 214 

Pus, 199 
basin, 112 

Putrefaction, cause of, 29 

Pyogenic cocci, 30 



Reaction. See Test. 
Recipes, diet, 299 
Rectal anesthesia, 166 

injections, 209 

irrigation, 209 
Rectum, examination of, 293 

instruments for resection of, 143 
Reiner's needle-holder, Noble's im- 
proved, 134 
Rennet, 303 
Resin plaster, 93 

Respiration, absence of, as sign of 
death, 307 

artificial, 267 
Respiratory tract, entrance of bac- 
teria into, 35 
Retractor, Buck's mastoid, 126 

Collins', 137 

Desmarre's lid, 130 

Kelly's, 13 7 

Mayo-Simpson's self-retaining, 
136 

Volkmann, 137 
Rice, boiled, 303 

plain, 303 
Richard's tonsil-holding forceps, 

128 
Rigor mortis, 307 
Rochester sterilizer, 108 
Rongeur forceps, Hudson's cranial, 

123 
Rubber adhesive plaster, 93 

dam, 184 

sterilization of, 188 

drainage-tubes, preparation of, 
187 



340 



INDEX 



Rubber-glove solution, 1! 

mesh. 184 

tissue, 184 
Rubber gloves, 188 



Salixe infusion, intravenous, 224 

solution, normal, 224 
Saprol, 59 
Saprophytes, 20 
Sarcina?, 30 
Saw. Gigli wire, 123 
Sayre's dressing, 03 
Scalpel. Mayo's, 132 
Scarification, 226 
Schizomycetes, 29 
Schleich's solutions for local anes- 
thesia. 169, 170 
Scissors, curbed, 133 

Emmett's angular bent, 133 

iris. 130 

Mayo's operating, 133 
Scopolamin-morphin anesthesia. 

166 
Scrambled eggs, 303 
Scultetus bandage, 92 
Segord's volsella forceps, 134 
Semmelweis' theory of puerperal 

fever, it, 
Sequelae of operations. 263 
Serum therapy, 44, 45 
Sheets, 184 
Shirred eggs, 303 

Shock, surgical, age factor in, 264 
artificial respiration in, 266 
mental condition in, 265 
susceptibility to. 264 
symptoms of, 265 
temperature in. 265 
treatment of, 265 
Shotted suture. 216 , 
Shoulder, spica bandage of, 77 

descending, 79 
Signs of death, 306. See also 

Death, signs of. 
Silk ligatures, 192 
Silkworm-gut, 193 
Silver nitrate poisoning, 232 
Sims' position, 291 

sharp curet, 138 

speculum, 138 
Sinus after operation, 275 



Sinexon's nasal dilator, 127 
Sleep, twilight, 166 
Slings, 92 
Snare, tonsil, 127 
Soap, green, 196 
Soda salts, poisoning by, 232 
Solutions, antiseptic, 64 
Sound, Simpson's uterine, 14c 
Soup, invalid's, 304 
tapioca, 302 
toast, 301 
Sozal, 59 
Spatula, iris, 130 

Speculum. Auvard's self-retaining. 
138 
Fox s eye, 130 
Sims', 138 
Spice-plasters, 218 
Spinal anesthesia, 172 
apparatus for, 172 
Babcock's solution for, 177 
centra-indications to, 177 
points for injection in, 173 
postoperative treatment, 177 
steps of, 175, 176 
technic of, 174 
Spirilli, 29 
Spirochaeta pallida, 44 

discovery of, 27 
Splenic fever, discovery of bacterial 

nature of, 23 
Splints, 99 

coaptation, 100 
plaster-cf-Paris, 100 
Sponges, gauze, 178 
keeping count of, 254 
marine, 179 
Spores, effect of heat on, 33 
formation of, ^2 
resistance of, 33 
Sporulation, 32 
Spotted fever, cause cf. 26 
Stacke's guard for facial nerve, 126 
Staphylococci, 30 

demonstration of, 31 
Staphylococcus epidermidis albus, 
42 
pyogenes albus, 42 
aureus, 30, 42 
citreus, 43 
Steam, disinfection by, 55 
Stegomyia fasciata, 26 






INDEX 



341 



Sterilization, 54, 105 

by. heat, 55 

fractional, 55 

intermittent, 55 

methods of, 102 

of catgut, 190 

of instruments, 106 

of. rubber dam, 188 

with boiling water, 55 
Sterilizer, 104 

bed-pan, in 

Rochester, 108 
Sterilizing outfit, 109 

room, 107, no 
Stethoscope, 306 

Griffith's anesthetizing, 148 
Stomach-contents, examination of, 
205 

instruments for operations on, 

131 

tube, 206 

method of passing, 205 
Stone's tissue forceps, 133 
Stone-searcher, Thompson's, 142 
Stramonium poisoning, 230 
Straps, catheter, 98 

Montgomery, 98 
Streptococci, 30 

Gram method of staining, 31 

antitoxin preparation of, 47 
Streptococcus lanceolatus, 43 

pyogenes, 42 
Stretcher, house, 103 

wheeled, 103 
Strychnin poisoning, 232 
Stump, recurrent bandage of, 87 
Stupe, turpentine, 217 
Sublimate gauze, 180 
Submucous resection, instruments 

for, 128 
Sunlight, effect of, on bacteria, 33 
Superheated steam, sterilization 

with, 55 
Surgeon's kit, 116 
contents of, 118 
packing of, 118 
Surgery, antiseptic, 20 

objects of, 239 
Surgical applications, 194 

procedures, minor, 215 

technic, 65 
Suspensory bandage of breast, 74 



Sutures, 190 

button, 216 

continuous, 216 

glovers', 216 

horsehair, 193 

interrupted, 216 

Pagenstecher, 192 

shotted, 216 

varieties of, 216 

wire, 193 
Suturing clamps, 216 
Sylvester's method of artificial res- 
piration, 267, 268 
Sypnilis, organism producing, 27, 

44 
Syringe cup, 277 
fountain, 285 
household bulb, 285 
Luer's hypodermic, 146 
nasal and ear, 277 



Tait's hemostat forceps, 134 
Tamarind water, 300 
Tampons, vaginal, 181, 182 
Tapioca jelly, 302 

pudding, 304 

soup, 302 
Tea, flaxseed, 301 
Technic, surgical, 65 
Temperature as sign of death, 308 

in surgical shock, 265 
Tendon, kangaroo, 192 
Test, tuberculin, 52 

Von Pirquet, 52 

Wassermann, 51 

Widal, 52 
Test-breakfast, 205 
Tetanus antitoxin, 50 

bacillus of, 43 
Tetrads, 30 
Thermocautery, 229 
Thermometer, bath, 208 

clinical, 228 
Toast, milk, 303 

soup, 301 

water, 301 
Thomas' dull curet, 138 
Thompson's stone-searcher, 142 
Throat, instruments for operations 

in, 125 
Thumb, bandage of, spica, 84 



342 



INDEX 



Thymol-iodid as germicide, 63 
Tincture of green soap, 196 
Tobacco poisoning, 232 
Tongue, instruments for, removal 

of, 129 
Tonsil snare, 127 
Tonsillotome, Ermold's, 128 
Tourniquet, Esmarch's,-27o 

Lentz's cranial chain, 123 
Towels, 184 

Transportation of patient, 249 
Traumatic delirium, 266 
Trays, glass, 112 

instrument, no 
Trendelenburg position, 283, 296 
Trephine, Hudson's cranial, 124 
Treponema pallidum, discovery of, 

Tropacocain anesthesia, 171 
Tuberculin, Koch's, 26 

test, 52 
Tuberculosis antitoxin, preparation 
of, 47 

bacillus of, 43 
discovery of, 25 

climatic control of, 37 

mode of infection in, 35 

sites of infection in, 36 

tests for presence of, 52 
Turpentine stupe, 217 
Twilight sleep, 166 
Tympanites after operation, 273 

enema for, 214 
Typhoid bacillus, discovery of, 24 

mode of infection in, 35 



Unna's paste, 195 
Upright position, 290 
Urinary fistula, 275 
Uterus, instruments for operations 
on, 135 



Vaccination, 219 
Vaccine, antityphoid, 50 
Vaginal douche, 207 
antiseptic, 208 
apparatus for, 209 
nozzle, 209 

hysterectomy, 275 

tampons, 181, 182 
Vapor apparatus for anesthesia, 151 

method of ether anesthesia, 152 
Velpeau's bandage, 78 
Venesection, 221 
Visitors after operation, 260 
Vclkmann retractor, 137 
Volsella forceps, Segond's, 134 
Von Pirquet test, 52 
Vulva, virginal, 201 

Watcher position, 293 
Wassermann test, 51 
Water, 299 

albumin, 299 

apple, 299 

barley, 299 

coil, 198 

lime-, 299 

tamarind, 300 

toast, 301 
Wax, Horsley's, 196 

Mosetig-Moorhof, 195 
Wecker's iris scissors, 130 
Wet cups, 220 
Widal test, 52 
Wire sutures, 193 

Yeasts, 29 

Yellow fever, method of transmis- 
sion, 26 

Zinc oxid adhesive plaster, 93 

salts, poisoning by, 232 
Zooglea, 30 



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first-year nursing work. It is the application of text-book 
knowledge. It tells the nurse how to do those things she is called 
upon to do in her first year in the training school — -the actual 
ward work. 

First-Year Nursing. By Minnie Goodnow, R. N m formerly Super- 
intendent of the Women's Hospital, Denver. wmoof 354 pages, 
illustrated. Cloth, $1.50 net. 



Aikens' Hospital Management 

This is just the work for hospital superintendents, training- 
school principals, physicians, and all who are actively inter- 
ested in hospital administration. The Medical Record says: 
"Tells in concise form exactly what a hospital should do 
and how it should be run, from the scrubwoman up to its 
financing." 

Hospital Management. Arranged and edited by Charlotte A. 
Aikens, formerly Director o l Sibley Memorial Hospital, Washing- 
ton, D. C. i2mo of 488 pages, illustrated. Cloth, $3.00 net 

Aikens' Primary Studies new (3 d) edition 

Trai?ied Nurse and Hospital Review says^ " It is safe to say 
that any pupil who has mastered even the major portion of 
this work would be one of the best prepared first year pupils 
who ever stood for examination." 

Primary Studies for Nurses. By Charlotte A. Aikens, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
471 pages, illustrated. Cloth, $1.75 net. 

Aikens' Training-School Methods and 
the Head Nurse 

This work not only tells how to teach, but also what should 
be taught the nurse and hozv much. The Medical Record sayss 
4 ' This book is original, breezy and healthy." 

Hospital Training-School Methods and the Head Nurse. By Char- 
lotte A. Aikens, formerly Director of Sibley Memorial Hospital., 
Washington, D. C i2tne of 267 pages. Cloth, $1.50 net 

Aikens' Clinical Studies NEW (2d) EDITION 

This work for second and third year students is written on the 
same lines as the author's successful work for primary stu- 
dents. Dietetic and Hygienic Gazette says there " is a large 
amount of practical information in this book." 

Clinical Studies for Nurses. By Charlotte A. Aikens, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
56g pages, illustrated Cloth, $2.00 net 



Bolduan and Grund's Bacteriology 

The authors have laid particular emphasis on the immediate 
application of bacteriology to the art of nursing. It is an 
applied bacteriology in the truest sense. A study of all the 
ordinary modes of transmission of infection are included. 

Applied Bacteriology for Nurses. By Charles F. Bolduan, M.D., 
Assistant to the General Medical Officer, and Marie Grund, A\.D., 
Bacteriologist, Research Laboratory, Department of Health, City of 
New York. i2mo of 166 pages, illustrated. Cloth, $1.25 net. 



Fiske's The Body 



A NEW IDEA 



Trained Nurse and Hospital Review says "it is concise, well- 
written and well illustrated, and should meet with favor in 
schools for nurses and with the graduate nurse." 

Structure and Functions of the Body. By Annette Fiske, A. M., 

Graduate of the Waltham Training School for Nurses, Massa- 
chusetts. 12010 of 221 pages, illustrated. Cloth, $1.25 net 



Beck's Reference Handbook 



NEW (3d) EDITION 



This book contains all the information that a nurse requires 
to carry out any directions given by the physician. The 
Montreal Medical Journal says it is "cleverly systematized ano 
shows close observation of the sickroom and hospital regime.' : 

A Reference Handbook for Nurses. By Amanda K. Beck, Grad* 
uate of the Illinois Training School for Nurses, Chicago, III. 
321110 volume of 244 pages. Bound in flexible leather, $1.25 net. 

Roberts' Bacteriology & Pathology 

This new work is practical in the strictest sense. Written 
specially for nurses, it confines itself to information that the 
nurse should know. All unessential matter is excluded. The 
style is concise and to the point, yet clear and plain. The text 
is illustrated throughout. 

Bacteriology and Pathofogy for Nurses. By Jay G. Roberts, Ph. G.. 

M. D., Oskaloosa, Iowa, nmo of 206 pages, illustrated. $1.25 net. 



DeLee's Obstetrics for Nurses SS 

Dr. DeL,ee's book really considers two subjects — obstetrics 
for nurses and actual obstetric nursing. Trained Nurse and 
Hospital Review says the "book abounds with practical 
suggestions, and they are given with such clearness that 
they cannot fail to leave their impress." 

Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of 
Obstetrics at the Northwestern University Medical School, Chicago. 
i2mo volume of 508 pages, fully illustrated. Cloth, $2.50 net. 

Davis' Obstetric & Gynecologic Nursing 

NEW (4th) EDITION 

The Trained Nurse a?id Hospital Review says: " This is one 
of the most practical and useful books ever presented to the 
nursing profession." The text is illustrated. 

Obstetric and Gynecologic Nursing. By Edward P. Davis, M. D., 
Professor of Obstetrics in the Jefferson Medical College, Philadel- 
phia, wmo volume of 480 pages, illustrated. Buckram, $1.75 net 

Macfarlane's Gynecology for Nurses 

NEW (2d) EDITION 

Dr. A. M. Seabrook, Woman's Hospital of Philadelphia, says: 
"It is a most admirable little book, covering in a concise but 
attractive way the subject from the nurse's standpoint." 

A Reference Handbook of Gynecology for Nurses. By Catharine 
Macfarlane, M. D., Gynecologist to the Woman's Hospital of Phila- 
delphia. 32mo of 156 pages, with 70 illustrations. Flexible leather,. 
$1.25 net. 

Asher's Chemistry and Toxicology 

Dr. Asher's one aim was to emphasize throughout his book 
the application of chemical and toxicologic knowledge in the 
study and practice of nursing. He has admirably succeeded. 

121T10 of 190 pages. By Philip Asher, Ph. G., M. D., Dean and Pro- 
fessor of Chemistry, New Orleans College of Pharmacy. Cloth, 
$1.25 net. 



Aikens' Home Nurse's Handbook 

The point about this work is this: It tells you, and shows you 
just how to do those little things entirely omitted from other 
nursing books, or at best only incidentally treated. The 
chapters on "Home Treatments" and "Every-Day Care of 
the Baby ; " stand out as particularly practical. 

Home Nurse's Handbook. By Charlotte A. Aikens, formerly Di- 
rector of the Sibley Memorial Hospital, Washing-ton, D. C. i2mo of 
276 pages, illustrated. Cloth. $1.50 net 

Eye, Ear, Nose, and Throat Nursing 

This book is written from beginning to end for the ?iurse. You 
get antiseptics, sterilization, nurse's duties, etc. You get an- 
atomy and physiology, common remedies, how to invert the 
lids, administer drops, solutions, salves, anesthetics, the 
various diseases and their management. New {2d) Edition. 

Nursing in Diseases of the Eye s Ear, Nose and Throat. By the 
Committee on Nurses of the Manhattan Eye, Ear and Throat Hospital. 
i2mo of 291 pages, illustrated. Cloth, $1.50 net 

Paul's Materia Medica NEW M edition 

In this work you get definitions — what an alkaloid is, an in- 
fusion, a mixture, an ointment, a solution, a tincture, etc. 
Then a classification of drugs according to their physiologic 
action, when to administer drugs, how to administer them, 
and how much to give. 

A Text-Book of Materia Medica for Nurses. By George P. Paul.M.D., 

Samaritan Hospital, Troy, N. Y. i2mo of 282 pages. Cloth, $1.50 net 

Paul's Fever Nursing NEW (3d ) edition 

In the first part you get chapters on fever in general, hygiene, 
diet, methods for reducing the fever, complications. In the 
second part each infection is taken up in detail. In the third 
part you get antitoxins and vaccines, bacteria, warnings of 
the full dose of drugs, poison antidotes, enemata, etc. 

Nursing in the Acute Infectious Fevers. By George P. Paul, M. D. 
i2moof 275 pages, illustrated. Cloth, $1.00 net 



McCombs' Diseases of Children for Nurses 

NEW (2d) EDITION 

Dr. McCombs' experience in lecturing to nurses has enabled 
him to emphasize/?^/ those points that ?iurses most need to know. 
National Hospital Record says: "We have needed a good 
book on children's diseases and this volume admirably fills 
the want." The nurse's side has been written by head 
nurses, very valuable being the work of Miss Jennie Manly. 

Diseases of Children for Nurses. By Robert S. McCombs, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo 
of 470 pages, illustrated. Cloth, $2.00 net 

Wilson's Obstetric Nursing new w edition 

In Dr. Wilson's work the entire subject is covered from the 
beginning of pregnancy, its course, signs, labor, its actual 
accomplishment, the puerperium and care of the infant. 
America?i Journal of Obstetrics says: " Every page empasizes 
the nurse's relation to the case." 

A Reference Handbook of Obstetric Nursing. By W. Reynolds 
Wilson, M.D., Visiting Physician to the Philadelphia Lying-in Char- 
?ty^ 32010 of 355 pages, illustrated. Flexible leather, $1.25 net. 



NEW (9th) EDITION 



American Pocket Dictionary 

The Trained Nurse and Hospital Review says: "We have 
had many occasions to refer to this dictionary, and in every 
instance we have found the desired information." 

American Pocket Medical Dictionary. Edited by W. A. Newman 
Dorland, A. M., M. D., Loyola University, Chicago. Flexible 
leather, gold edges, $1.00 net; with patent thumb index, $1.25 net. 



THIRD 
EDITION 



Lewis' Anatomy and Physiology 

Nurses Joarnal of Pacitic Coast says * ' it is not in any sense 
rudimentary, but comprehensive in its treatment of the sub- 
jects." The low price makes this book particularly attractive. 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., Lec- 
turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay 
City, Mich. i2mo of 326 pages, 150 illustrations. Cloth, $1.7? net 



Bohm & Painter's Massage 

The methods described are those employed in Hoffa's Clinic 
— methods that give results. Every step is illustrated, showing 
you the exact direction of the strokings. The pictures are 
large. You get the technic used in Professor Hoffa's Clinic. 

Octavo of qi pages, with 97 illustrations. By Max Bohm, M. D., 
Berlin, Germany. Edited by Charles F. Painter, M. D., Professor 
or Orthopedic Surgery, Tufts College Medical School, Boston. 

Cloth, $1.75 net 



SECOND 
EDITION 



Grafstrom's Mechano-therapy 

Dr. Grafstrom gives you here the Swedish system of mechan- 
otherapy. You are given the effects of certain movements, 
gymnastic postures, medical gymnastics, general massage 
treatment, massage for the various conditions. The illustra- 
tions are full-page line drawings. 

Mechanotherapy (Massage and Medical Gymnastics). By AXEL V. 
Grafstrom, B. Sc, M. D., Attending Physician Gustavus Adolphus 
Orphanage, Jamestown, New York. i6mo of 200 pages. 

Cloth, $1.25 net 

Friedenwald and Ruhrah's Dietetics for 

IN UfSeS NEW (3d) EDITION 

This work has been prepared to meet the needs of the nurse, 
both in training school and after graduation. American Jour- 
nal of Nursing says it "is exactly the book for which nurses 
and others have long and vainly sought." 

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor of 
Diseases of the Stomach, and John Ruhrah, M.D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
i2mo volume of 431 pages. Cloth, $1.50 net 



FOURTH 
EDITION 



Friedenwald & Ruhrah on Diet 

This work is a fuller treatment of the subject of diet, pre- 
sented along the same lines as the smaller work. Everything 
concerning diets, their preparation and use, coloric values, 
rectal feeding, etc., is here given in the light of the most re- 
cent researches. 

Diet in Health and Disease. By Julius Friedenwald, M.D., and 
John Ruhrah, M.D. Octavo volume of 857 pages. Cloth, $4.00 net 



Pyle's Personal Hygiene new «*) edition 

Dr. Pyle's work discusses the care of the teeth, skin, com- 
plexion and hair, bathing, clothing, mouth breathing, catch- 
ing cold; singing, care of the eyes, school hygiene, body 
posture, ventilation, heating, water supply, house-cleaning, 
home gymnastics, first-aid measures, etc. 

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., 
Wills Eye Hospital, Philadelphia. i2mo, 543 pages of illus. $1.50 net 

Galbraith's Personal Hygiene and Physical 
Training for Women illustrated 

Dr. Galbraith's book tells you how to train the physical pow- 
ers to their highest degree of efficiency by means of fresh air, 
tonic baths, proper food and clothing, gymnastic and outdoor 
exercise. There are chapters on the skin, hair, development 
of the form, carriage, dancing, walking, running, swimming, 
rowing, and other outdoor sports. 

Personal Hygiene and Physical Training for Women. By Anna M. 
Galbraith, M.D., Fellow New York Academy of Medicine. i2mo of 
371 pages, illustrated. Cloth, $2.00 net 

Galbraith's Four Epochs of Woman's Life 

This book covers each epoch fully, in a clean, instructive way, 
taking up puberty, menstruation, marriage, sexual instinct, 
sterility, pregnancy, confinement, nursing, the menopause. 

The Four Epochs of Woman's Life. By Anna M. Galbraith, M. D. 
With an Introductory Note by John H. Musser, M. D., University of 
Pennsylvania. i2mo of 247 pages. Cloth, $1.50 net 

Griffith's Care of the Baby NE w w edition 

Here is a book that tells in simple, straightforward language 
exactly how to care for the baby in health and disease ; how 
to keep it well and strong; and should it fall sick, how to 
carry out the physician's instructions and nurse it back to 
health again. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Univers- 
ity of Pennsylvania, nmo of 458 pages, illustrated. Cloth, $1.50 net 



Aikens' Ethics for Nurses just ready 

This book emphasizes the importance of ethical training. It 
is a most excellent text-book, particularly well adapted for 
classroom work. The illustrations and practical problems 
used in the book are drawn from life. 

Studies in Ethics for Nurses. By Charlotte A. Aikens, formerly 

Superintendent of Columbia Hospital, Pittsburg, nmo of 318 pages. 

Cloth, $1.75 net. 

Goodnow's History of Nursing ready soon 

Miss Goodnow's work gives the main facts of nursing history 
from the beginning to the present time. It is suited for class- 
room work or postgraduate reading. Sufficient details and 
personalities have been added to give color and interest, and 
to present a picture of the times described. 

History of Nursing. By MINNIE Goodnow, R.N., formerly Super- 
intendent of the Women's Hospital, Denver. i2mo of 300 pages, 
illustrated. 



READY 
SOON 



Berry's Orthopedics for Nurses 

The object of Dr. Berry's book is to supply the nurse with a 
work that discusses clearly and simply the diagnosis, prog- 
nosis and treatment of the more common and important ortho- 
pedic deformities. Many illustrations are included. The 
work is very practical. 

Or.hopedic Surgery for Nurses. By John McWilliams Berry, 
M.D., Clinical Professor of Orthopedics and Rontgenology, Albany 
Medical College. i2mo of 100 pages, illustrated. 

Whiting's Bandaging 

This new work takes up each bandage in detail, telling you — 
and showing you by original illustrations — just how each 
bandage should be applied, each turn made. Dr. Whiting's 
teaching experience has enabled him to devise means for over- 
coming common errors in applying bandages. 

Bandaging. By A. D. Whiting, M.D , Instructor in Surgery at the 
University of Pennsylvania. i2mo of 151 pages, with 117 illustra- 
tions. Cloth, $1.25 net. 

10 



Hoxie & Laptad's Medicine for Nurses 

Medicine for Nurses and Housemothers. By George 
Howard Hoxie, M. D., University of Kansas; and 
Peari, Iv. Laptad. 12mo of 351 pages, illustrated. 
Cloth, $1.50 net. New {2d) Edition. 

This book gives you information that will help you to carry out the 
directions of the physician and care for the sick in emergencies. It 
teaches you how to recognize any signs and changes that may occur be- 
tween visits of the physician, and, if necessary, to meet conditions until 
the physician's arrival. 

Boyd's State Registration for Nurses 

State Registration for Nurses. By Louie Croft Boyd, 
R. N., Graduate Colorado Training School for Nurses. 
Octovo of 149 pages. Cloth, $1.25 net. New {2d) Edition. 

Morrow's Immediate Care of Injured 

Immediate Care of the Injured. By Albert S. Mor- 
row, M. D., New York City Home for Aged and In- 
firm. Octavo of 354 pages, with 242 illustrations. 
Cloth, $2.50 net. New {2d) Edition. 

deNancrede's Anatomy new &*> edition 

Essentials of Anatomy. By Charles B. G. deNan- 
crede, M. D., University of Michigan. 12mo of 400 
pages, 180 illustrations. Cloth, $1.00 net. 

Morris' Materia Medica NE w (7 rh> edition 

Essentials of Materia Medica, Therapeutics, and Pre- 
scription Writing. By Henry Morris, M. D. Re- 
vised by W. A. Bastedo, M. D., Columbia University, 
New York. 12mo of 300 pages, illustrated. 

Cloth, $1.00 net. 

Register's Fever Nursing 

A Text Book on Practical Fever Nursing. By Edward 
C. Register, M. D., North Carolina Medical College. 
Octavo of 350 pages, illustrated. Cloth, $2.50 net. 



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